Form | Dentix24 Dental Clinic

24/7 Dental Emergency

(416) 483-0000

Medical History & Consent Form

Title

Full Name

Date Of Birth

Occupation

Phone Number

Email Address

Street Address

Postal Code

City

Who referred you to our office?

In case of emergency, notify (name)

Relationship

Emergency Phone Number

Family doctor (name)

Family doctor phone

Medical Specialist 1 (name)

Area of speciality 1

Medical Specialist 1 (Phone)

Medical Specialist 2 (name)

Area of speciality 2

Medical Specialist 2 (Phone)

1. Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain.

Yes No Not Sure/Maybe

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year? If yes, please explain.

Yes No Not Sure/Maybe

4. Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?

Yes No Not Sure/Maybe

5. Do you have any allergies? If yes, please specify:

Yes No Not Sure/Maybe

a) medications b) latex / rubber products c) other (e.g. hay fever, foods)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

Yes No Not Sure/Maybe

7. Do you have or have you ever had asthma?

Yes No Not Sure/Maybe

8. Do you have or have you ever had any heart or blood pressure problems?

Yes No Not Sure/Maybe

9. Do you have or have you ever had a replacement or repair of a heart valve, infective endocarditis, congenital heart disease, or a heart transplant?

Yes No Not Sure/Maybe

10. Do you have a prosthetic or artificial joint?

Yes No Not Sure/Maybe

11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS/HIV, radiotherapy, chemotherapy)?

Yes No Not Sure/Maybe

12. Have you ever had hepatitis, jaundice or liver disease?

Yes No Not Sure/Maybe

13. Do you have a bleeding problem or bleeding disorder?

Yes No Not Sure/Maybe

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

Yes No Not Sure/Maybe

15. Have you ever had any of the following? (Check all that apply)

16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.

Yes No Not Sure/Maybe

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? If yes, please explain.

Yes No Not Sure/Maybe

18. Do you smoke or chew tobacco products?

Yes No Not Sure/Maybe

19. Are you nervous during dental treatment?

Yes No Not Sure/Maybe

20. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

Yes No Not Sure/Maybe

Expected delivery date (if pregnant)

21. Do you identify as a patient with a disability? If yes, please explain.

Yes No Not Sure/Maybe

Patient, Parent, or Guardian Signature *

Clear

1. Consent for Examination and Diagnostic Records

I consent to an oral examination and authorize Dentix24 Dental Clinic to take dental radiographs (x-rays), photographs, and other diagnostic records as deemed necessary for diagnosis, treatment planning, documentation, quality assurance, and legal record-keeping.

I understand that I may refuse or withdraw this consent at any time, subject to professional, ethical, and legal obligations.

2. Financial Responsibility, Insurance, and Late Payment

I understand that dental insurance is a contract between myself and my insurance provider. I acknowledge that insurance estimates are not a guarantee of payment.

I agree that I am financially responsible for all fees incurred, including any portion not paid by my dental benefit plan. I authorize Dentix24 to submit insurance claims electronically on my behalf where applicable.

For patients without dental insurance, payment in full is due on the date of service unless prior arrangements have been approved in writing.

Accounts with outstanding balances may be subject to administrative or collection fees and/or referred for collection if payment is not received within a reasonable period of time.

3. Appointment and Cancellation Policy

Appointment times are reserved exclusively for me. I understand that a minimum of two (2) business days’ notice is required to change or cancel an appointment.

Failure to provide adequate notice, or failure to attend a scheduled appointment, may result in a missed-appointment or cancellation fee.

4. Communication Consent

I authorize Dentix24 Dental Clinic to contact me regarding appointments and administrative matters via voicemail, email, and text message.

5. Privacy and Confidentiality

I acknowledge that my personal health information will be collected, used, and disclosed in accordance with applicable privacy legislation (PHIPA) and Dentix24 Dental Clinic’s privacy policies.

6. Third-Party Attendance and Minor Responsibility

If someone other than the parent(s) or legal guardian(s) listed below will accompany the patient to appointments, their name(s) must be provided.

I understand that accompanying individuals are not authorized to consent to treatment unless legally permitted or explicitly authorized in writing.

For minor patients, the parent or legal guardian signing below accepts full financial responsibility for all services rendered.

Names of accompanying individuals (if applicable)

7. Acknowledgment and Consent

I acknowledge that I have read and understood this consent and office policies. *

Patient Name

Signature

Clear

Parent / Legal Guardian Name (if applicable)

Parent / Legal Guardian Signature (if applicable)

Clear

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New patient appointments paused 2AM – 6AM for essential overnight sterilization safety procedures.

Thank You for Your Understanding!

Medical History & Consent Form

Patient Information

Emergency Contact

Medical Contacts

General Health & Recent Treatments

Patient Consent & Office Policies