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#208 - 3929 8th St E, Saskatoon, SK
306-955-4611
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Update Medical History
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Patients
New Patients
New Patients (Children 10 and Under)
Update Medical History
Services
Our Staff
Contact Us
Update Medical History
Please fill out the form below.
Patient Name:
First
Middle
Last
Date of Birth:
Day
Month
Year
Height:
Weight:
Gender:
Pronouns, if you wish to specify:
Has there been any change in your health in the past year?
Yes
No
Are you currently under the care of a physician?
Yes
No
Last medical checkup:
Are you pregnant or nursing?
Yes
No
Do you have any of the following?
Congenital Heart Disease
Pacemaker
Heart Disease
Chest Pain/Angina
High Blood Pressure
Heart Attack
Heart Surgery
Stroke
Heart Murmur
Prosthetic Heart Valve
Diabetes
Kidney Disorder
Liver Disease/Hepatitis/Jaundice
Thyroid/Glandular Disorder
Lung Disease/COPD
Asthma
Sleep Apnea/CPAP
Cancer/Cancer Treatment
Radiation Therapy to Head/Neck
Stomach Ulcers/GERD
Abdominal Bleeding
Blood Disorder
Epilepsy/Seizures
Glaucoma
Osteoporosis
HIV/AIDS
Knee or Hip Replacement
Rheumatoid Arthritis
Immune Deficiency
Inflammatory Bowel Disease
Depression/Anxiety
Alcohol/Drug Dependance
Previous Injury to Face/Jaw
Sinus Issues
Cognitive Disability
Hormone Replacement Therapy
Dental Anxiety
Other
Please list any other medical conditions (you can also use this space to provide more details on any of the conditions indicated above):
Please list any surgical procedures in the past:
Please list all medications that you are currently taking, both prescription and non-prescription, or provide us with a list:
Do you have any allergies (medications or other)?
Yes
No
If yes, please list:
Do you smoke or vape?
Yes
No
If yes, for how many years and how much:
Do you drink alcohol?
Yes
No
If yes, how much:
Do you use cannabis?
Yes
No
If yes, how much and in what form?
Do you use other recreational drugs?
Yes
No
Work Phone:
Cell Phone:
Home Phone:
Email
Health Card Number:
Province
Spouse/Parent Name:
Employer/Occupation:
Referred by:
This is to certify that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures. I acknowledge reviewing the College Park Dental Privacy Policy and understand my rights of privacy and respect to me (and any dependent children) personal information. I further consent to the collection, use and disclosure of my (or dependent child’s) personal information.
Please check the following boxes.
Consent
(Required)
To provide dental services;
To maintain communications with healthcare specialists and to provide me (us) with information and follow up respecting my dental care;
To communicate with my insurance plan(s) to facilitate the processing of my claims;
For the uses, purposes, and disclosures described in the privacy act
Phone
This field is for validation purposes and should be left unchanged.
Proudly serving Saskatoon and area since 1986.
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