Address: 1365 Beaverbrook Ave. Unit 102 London, Ontario N6H 0J1

Phone: (519) 641-1411

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Medical History Form

The information below is very important. Please make it as complete and accurate as you can. This information becomes part of your patient records. Our office follows the PHIPA Act

Personal Information

Date of birth

Medical Information

Dental History

WOMEN ONLY

I confirm that all the medical and dental information provided above is true to the best of my knowledge, and I have not omitted any information. I also consent to my physician being contacted if necessary, to obtain any information that is required for my dental care.