• Laurier Dental

  • 500 Laurier Avenue, Milton, Ontario L9T 4R3 (905) 878-9882

  • MEDICAL HISTORY QUESTIONNAIRE

  • MEDICAL ALERT:

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  • IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

  • The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

  • I, the undersigned, acknowledge that I have provided an accurate personal medical/dental history. I will inform you if there are any changes in my health or medications at future appointments. Dr. Summer Al Maqdassy or her staff may contact my physician, if necessary, to discuss any relevant medical information. I, the undersigned, consent to the performing of dental procedures, x-rays, and diagnostic tests agreed to be necessary or advisable for this case.

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