905-696-7500
info@worlddrivedentistry.com
70 World Drive
Mississauga, ON
Home
About Us
About Us
Meet the Team
Office Tour
Dental Services
We Are Accepting New Patients !
Dental Implants in Mississauga
Dentistry for Your Children
Cosmetic Dental Bonding
Invisalign
Dental Check up
Dentures-partials-complete-Implant supported
Root Canal Treatment
Teeth Cleaning and Whitening
Wisdom Tooth Extraction
Bite Guards
Sports Mouth Guard
Anti Snore Appliances
Patient Services
COVID-19 Intake Screener
Your First Visit
New Patient Forms
Patient Financial Info
Post Treatment Instructions
Specials
Dental Technologies
Digital X-Ray
Digital Office
Oral Cancer Screening – Using Velscope
FAQ
Contact Us
Book Now
Home
About Us
About Us
Meet the Team
Office Tour
Dental Services
We Are Accepting New Patients !
Dental Implants in Mississauga
Dentistry for Your Children
Cosmetic Dental Bonding
Invisalign
Dental Check up
Dentures-partials-complete-Implant supported
Root Canal Treatment
Teeth Cleaning and Whitening
Wisdom Tooth Extraction
Bite Guards
Sports Mouth Guard
Anti Snore Appliances
Patient Services
COVID-19 Intake Screener
Your First Visit
New Patient Forms
Patient Financial Info
Post Treatment Instructions
Specials
Dental Technologies
Digital X-Ray
Digital Office
Oral Cancer Screening – Using Velscope
FAQ
Contact Us
Book Now
Form Testing - World Drive Dentistry
875
page-template-default,page,page-id-875,bridge-core-1.0.4,ajax_fade,page_not_loaded,,qode_grid_1300,footer_responsive_adv,qode-theme-ver-18.0.9,qode-theme-bridge,qode_header_in_grid,wpb-js-composer js-comp-ver-5.7,vc_responsive
Form Testing
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Name
*
Todays Date
Date of Birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Contact Info
Phone (copy) (copy)
Cell Phone
Email
Email Address
Who to Thank?
Who do we have to thank for referring you to our office?
Next
Dental Insurance Information - Primary
Member's Name
Member's Name and DOB( dd/mm//yy)
Insurance Company
Insurance Company
Employer
Employer
Policy / Group
Policy / Group number
Certificate / ID
Certificate / ID number
Dental Insurance Information - Secondary
FILL IF APPLICABLE
Member's Name (copy)
Member's Name and DOB( dd/mm/yy)
Insurance Company (copy)
Insurance Company
Employer (copy)
Employer
Policy / Group (copy)
Policy / Group
Certificate / ID (copy)
Certificate / ID
Previous
Next
Dental History
When did you last see a dentist?
Last Full Mouth X-Rays
Last Full Mouth X-Rays(approximately )
Are you experiencing any problems now?
Yes
No
What Problems are You Experiencing?
If yes, please explain
Do you wear Dentures (Partials or Full)
Yes
No
Are you apprehensive about dental treatment?
Yes
No
Do your gums bleed or feel tender or irritated?
Yes
No
Are your teeth sensitive to hot/ cold
Yes
No
Are you unhappy with the appearance of your teeth?
Yes
No
Are you aware of Grinding or Clenching your teeth?
Yes
No
Do you have frequent headaches, ear aches or neck pain?
Yes
No
Have you worn braces on your teeth?
Yes
No
Do you have discoloured teeth that bother you?
Yes
No
Would you like your smile to look better or different?
Yes
No
Do you regularly use Dental Floss?
Yes
No
Previous
Next
Medical History
Family Physician
Family Physician and contact details
Do you have any current health problems?
Yes
No
Are you currently under a physician's care?
Yes
No
If yes, please explain
What medications are you taking?
What medications are you taking?
Do you use Cigars/Cigarettes, Pipe or Chewing Tobacco?
Yes
No
For women, are you taking birth control pills?
Yes
No
Have you ever been diagnosed with or treated for any of the following conditions?
Diabetes/High Or Low Blood Pressure/cardiac disease/Asthma or other respiratory disease/Cancer -Chemotherapy/Bleeding disorder/Epilepsy/Anxiety/
Yes
No
AIDS/HIV Positive, Rhematic fever, Shingles, Venereal diseases, Herpes, Hepatitis A/B/C, Arthritis, Artificial Joints, Chronic Cough, Tonsillitis, Glaucoma, Skin Rash
Yes
No
If yes please supply further details
Are you allergic to any of the following medications? Aspirin ,Erythromycin,Nitrous oxide, Codeine,Penicillin,Latex please specify if applicable
YES
MARK YES IF ANY APPLY
Is there any medical or dental information that you feel we should know about?
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of my treatment or examination rendered to me or my child or an individual under my guardianship during the period of such dental care to third party payers and or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less then the actual bill for services. I agree to be responsible for payment of all services rendered.
Print name for signature
Previous
Phone
Submit