- My Forms at Home

HygieneHygiene

Book your appointment for Hygiene lasting [45 minutes].

Any Available Provider

Dr. Rai

Dr. Daudi

Book your appointment for Hygiene lasting [45 minutes].

Earliest available appointment date is on Jun 9, 2026

Available Dates

Available Times

Available times will appear once a date is selected.

Confirm Appointment
Hygiene [45 minutes]

Message for office (optional) If you are able to provide any details for your appointment, please list them below:

20260609,20260616,20260623,20260630,

NEW PATIENT CONTACT

Please spend a few minutes completing this New Patient Health History Form. Once complete, click on the Submit Button. This information will then be submitted to your Dental Office securely. If you wish to keep a copy for yourself, please click on the Print Button or simply click on File and Save As.

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Phone #

Type

Ext

Preferred Phone

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

INSURNACE & BENEFITS

Below, please indicate any and all insurnace information that may be relevant to your dental coverage.

Please be advised: We do not accept ODSP / CDCP Patients at this time.

Humber Students:
PLEASE PUT YOUR STUDENT NUMBER AS YOUR 'SUBSCRIBER ID' THEN MOVE ON TO THE REST OF THE FORM.

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

MEDICAL HISTORY

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following questions.

Have you ever been hospitalized for a serious illness or extensive medical care?

Yes

If yes, please specify:

Are you presently under the care of a physician?

Yes

If yes, please specify their name:

Have you had any medical examination in the past year?

Yes

If yes, please specify:

Do you take any prescription or non-prescription drugs regularly?

Yes

If yes, please specify:

Have you ever experienced any unusual reactions to any of the following...

Penicillin

Sulfa Drugs

Erythromycin

Barbiturates

Asprin

Local Anaesthesia (Freezing)

Codeine

Other:

Do you have any of the following allergic conditions:

Hay Fever

Skin Rash

Latex

Metal

Food allergy? Specify:

Have you been warned against taking any drugs or medication?

Yes

If yes, please specify:

Do you have - or have ever had - any of the following:

Heart Murmur or Mitral Valve Prolapse

Stomach / Intestinal issues or Ulcers

Cortisone / Steroid Therapy

High / Low Blood Pressure

Heart Attack

Jaundice

Joint Replacement

Venereal Disease / Herpes

Rheumatic Fever

Lung Disease

Epilepsy or Seizures

Malignant Hyperthermia

Glaucoma

Thyroid Disease

Kidney / Renal Problems

Sinus Troubles

Cancer / Chemotherapy Treatment

Liver Disease

Asthma

Hepatitis A / B / C

Diabetes

Do you have AIDS or have ever tested positive for HIV?

Yes

Have you ever had any organ implants or medicinal implants?

Yes

Do you bleed or bruise easily?

Yes

Have you ever fainted?

Yes

Do your ankles swell?

Yes

Do you experience shortness of breath or chest pains upon exertion?

Yes

Do you have frequent headaches / migraines?

Yes

Do you smoke / vape? Specify approximately how many cigarette equivalents per day (if not applicable enter value '0')

Have you had any injury, sugery or X-Ray therapy to your face or jaw?

Yes

If yes, please specify when the injury, surgery or therapy occured

Do you have any disease, condition, or problem that you think the dentist should know about? Specify:

Are you or could you be pregnant?

Yes

If yes, what is the expected delivery date?

Are you taking birth control pills?

Yes

DENTAL HISTORY

Please go over the following section and indicate your relevant dental history below.

Reason for today's visit:

Exam

Cleaning

Emergency

Other

How frequently do you see your dentist?

3 Months

6 Months

Yearly

> Yearly

When was your last dental visit?

If applicable, name of your former dentist:

How often do you brush your teeth?

> 2x per day

2x per day

1x per day

< 1x per day

I don't brush...

How often do you floss?

> 2x per day

2x per day

1x per day

< 1x per day

I don't floss...

Are you teeth sensitive to either:

Hot

Cold

Sweet

Biting

N/A

Do your gums bleed easily?

Yes

Do you feel you have bad breath?

Yes

Do you grind your teeth or does your jaw hurt / crack or pop?

Yes

Have you had any of the following:

Braces

Extraction

Gum Treatment

Root Canal

N/A

Have you experienced any growths or soreness inside your mouth?

Yes

Are you happy with the appearance of your teeth?

Yes

Do you have any other dental concerns or topics you'd like to bring up with the dentist?

Office Policies & Patient Release
Employer or government sponsored plans are a benefit provided to you to help you stay healthy. A dental plan is a way of helping you defray the cost of dental care but not all dental plans will cover the treatment you may need. Any portion not covered by your plan is your responsibility.

Your appointment time is reserved especially for you. Thereby, we require at least 48 hours notice of any changes or cancellations to your appointment. A fee of $25.00 will be applied to your account for single 'short-notice-cancellations,' or 'failure to show for appointment' vis-a-vis the timeframe aformentioned. Habitual cancellations, alterations or failure to shows will result in an additional $25.00 added per missed appointment - i.e. 2nd missed appointment will be $50.00, 3rd $75.00.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that responsibility fror payment for the dental services provided for myself and my dependants is mine, and I will assume the responsibility for fees associated with these services.

SIGN HERE