Our Community

We are excited to announce our new location in Vaughan! Crystalline Dental is conveniently located in the Walmart Supercentre plaza and provides ample parking. Our facility is fully accessible and wheelchair friendly.

Email: info@crystallinedental.com
Phone: +1 905 303-0700
Fax: +1 905 303-2333

Prefix

First Name

Last Name

Date of birth

Dental InsuranceYesNo

ADDRESS:

Phone *

Email Address *

WHO REFERRED YOU TO OUR OFFICE?

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

NAME

RELATIONSHIP

DAY-TIME PHONE

NAME OF FAMILY DOCTOR

PHONE

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.

1. Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year? If yes, please explain.

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them.

5. Do you have any allergies? If yes, please list them using the categories below:

Medications

latex/rubber products

ther (e.g. hay fever, seasonal/environmental, foods)

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.

7. Do you have or have you ever had asthma?

8. Do you have or have you ever had any heart or blood pressure problems?

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

10. Do you have a prosthetic or artificial joint?

11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?

12. Have you ever had hepatitis, jaundice or liver disease?

13. Do you have a bleeding problem or bleeding disorder?

14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?

18. Do you smoke or chew tobacco products?

19. Are you nervous during dental treatment?

20. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

21. Do you identify as a patient with a disability? If yes, please explain.

To the best of my knowledge, all 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.

Our Community

Hours Mon: 9am-4pm Tue: 8am-7pm Wed: Closed Thu: 9am-5pm Fri: 9am-4pm Sat: 9am-5pm Sun: Closed

Hours
Mon: 9am-4pm
Tue: 8am-7pm
Wed: Closed
Thu: 9am-5pm
Fri: 9am-4pm
Sat: 9am-5pm
Sun: Closed