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5 Year Medical History Update
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Book An Appointment
Home
About
About Kitchener Dentist Frederick
Review Us
Periodontal Services
Dental Procedures
Preventive Periodontal Treatment
Complete Dental Examination
Dental x-Rays
Digital x-Rays
Fluoride Treatment
Home Care
Oral Hygiene Aids
Sealants
Dental Prophylaxis (Professional Dental Cleaning)
Periodontal Treatment
Antibiotic Treatment
Bone Grafting for Periodontal Disease
Bruxism
Crown Lengthening
Gum Grafting
Gum Recession
Oral Cancer Exam
Periodontal Scaling & Root Planing
Pocket Irrigation
Pocket Reduction Surgery
Restorative Procedures
Ridge Modification
Sinus Augmentation
Soft Tissue Grafting
Periodontal Disease
What Is Periodontal Gum Disease
Diagnosis
Treatment
Maintenance
Causes Of Periodontal Disease
Types Of Periodontal Disease
Signs Symptoms Of Periodontal Disease
Mouth Body Connection
Periodontal Disease And Diabetes
Periodontal Disease Heart Disease And Stroke
Periodontal Disease And Pregnancy
Periodontal Disease And Osteoporosis
Periodontal Disease And Respiratory Disease
Restorations
Amalgam Fillings
Crowns Caps
Dentures Partial Dentures
Fixed Bridges
Inlay Restorations
Onlay Restorations
Endodontics
Cracked Tooth
Root Amputation
Root Canal Retreatment
Root Canal Therapy
Dental Implants
Teeth in A Day
Single Tooth Replacement
Multiple Teeth Replacement
Full Arch Implant Retained Devices
Dental Implants Faqs
Cosmetic Dentistry
Porcelain Crowns
Porcelain Inlays
Porcelain Veneers
Porcelain Fixed Bridges
Porcelain Onlays
Teeth Whitening
Composite Fillings
Patient Info
Initial Dentist Appointment
Patient Forms
New Patient Form
Medical History Update
5 Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
Payment Options
FAQs
Blog
Book An Appointment
5 Year Medical History Update
5 Year Medial Update Form
Kitchener Dentist Centre - Sorin Boeriu DDS
866 Frederick Street
Kitchener, ON N2B 2B8 Canada
Phone: (519) 578-7830
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Medical & Dental Information
Do you or have you ever had an adverse reaction or allergy to:
Antibiotic
Yes
No
Which Antibiotic
Aspirin/Advil
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No
Codeine
Yes
No
Latex
Yes
No
Local Anesthetics/Novocain
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Other
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Do you take blood thinners (e.g Coumadin, Plavix, etc.)
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Specify the date and score of most recent INR
Do you take any other medications, vitamins or supplements
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Have you ever had any of the following? Please check those that apply:
Neural
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Where do you keep your inhaler?
Specify any of the above conditions
Surgery Details
If you had any surgeries please specify the surgery date and information.
Are there any conditions or diseases not listed above that you have or have had?
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What are they?
Have you ever had any complications following dental treatment?
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Please explain
Have you or anyone related to you ever had problems with local anesthetic?
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No
Please explain
Are you pregnant or is it possible you are pregnant?
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Due Date
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Are you now under the care of a physician, regarding an ongoing medical issue?
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Please explain
Do you have any health problems that need further clarification?
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Do you smoke?
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Yes
No
Used to
How many cigarettes a day?
When did you quit?
Day
Month
Year
Do you use any recreational drugs?
*
Yes
No
Please list which kind:
Do you have a prosthetic or artificial joint ?
*
Yes
No
Where ?
Do you have or have you ever had replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?
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Yes
No
When was your last dental visit ?
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When did you last have dental x-rays ?
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How often do you floss your teeth ?
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How often do you brush your teeth ?
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Have you been seeing a dentist regularly ?
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No
Do any of your teeth ache ?
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Yes
No
Do your gums bleed when you brush ?
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Yes
No
Do you have pain when you chew ?
*
Yes
No
Do you feel you have bad breath ?
*
Yes
No
Please list anything else not mentioned above regarding your past dental history.
Consent for Services & Office Agreement
* I understand that my family’s appointments are valuable, and that
2 Business days
must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.
*I will be required to
pay for my family treatment at each visit
. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).
*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.
*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.
*
My dental insurance plan is a contract between myself and the organization providing me with the coverage
. It is my responsibility to ensure that the treatment I request is covered. However, Sorin Boeriu DDS will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Sorin Boeriu DDS has
NO
knowledge of what is covered by my insurance plan. If I have a booklet, Sorin Boeriu DDS will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Sorin Boeriu DDS will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.
* Sorin Boeriu DDS also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.
* Sorin Boeriu DDS will always make every attempt to see emergency cases promptly.
* Sorin Boeriu DDS will accept Visa, MasterCard, debit, cash or cheque.
* Sorin Boeriu DDS will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.
Consent for Collection, Use and Disclosure of Personal Information
* I agree that Sorin Boeriu DDS has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.
Consent
*
I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian (Type in Your Name)
Date
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