New Client Age 16+ Medical & Dental Form

Emergency contact name, relationship and phone number

Have you been diagnosed with a cardiac (heart) condition or any condition that requires antibiotic prophylaxsis befoe dental treatment. Such as a prosthetic heart valve, heart transplant with abnormal heart valve fnction, congenital heart defects or joint replacement. If yes please list.

Have you had a knee, hip or joint replacement and if so which joint and what year did you have the replacement?

Are you allergic to any medications, foods, drugs, metals or latex? If yes please list your allergies.

Please list any herbal remedies and vitamins that you are taking along with the dose and reason why you are taking them?

Do you smoke tobacco cigarettes?

What dental conditions or concerns do you have?

& Peter Rotsaert Denturist

Dental Hygiene Services & Denture Appointments For The Niagara Region

Welcome to Heritage Dental Hygiene!

For ages 16 years and older please complete this medical & dental history form before your appointment.

Welcome to Heritage Dental Hygiene!

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For ages 16 years and older please complete this medical & dental history form before your appointment.