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?

Follow me on Instagram for oral hygiene info, and what's happening behind the scenes.

Amie Banting

& Peter Rotsaert Denturist

Open By Appointment Only

Dental Hygiene Services & Denture Appointments For The Niagara Region

During the Ontario, Canada Province-wide emergency break (closure) effective April 3, 2021 HERITAGE DENTAL HYGIENE IS OPEN BY APPOINTMENT ONLY AND I AM OPERATING AS AN ESSENTIAL WORKER.

As a result of the COVID-19 pandemic, the office will be OPEN by Appointment only.

All product pickups, Dental Hygiene & Denturist appointments must be scheduled. To do our part to keep everyone safe our office requires anyone entering or exiting the office to follow the COVID-19 symptom screening protocol and complete a virtual screening form.

Heritage Dental Hygiene has the College Of Dental Hygienists Of Ontario guidelines in place to perform aerosol-generating procedures during the COVID-19 pandemic including full-provider PPE, a closed operatory, air exchange, and HEPA filtration.

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.