Patient Medical Information Form

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Power of Attorney Information:
Same as resident?
If different from resident:
Power of attorney name:
Are you being treated for any medical conditions at the present time or have been treated the last year?
Have there been any changes in your general health in the last year?
Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?
Do you have any allergies?
Have you ever had an uncommon or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a prosthetic cardiac valve or valve repair?
History of infective endocarditis?
Cardiac transplant with valve regurgitation?
Congenital (present at birth) heart defect or disease?
Have you ever had hepatits, jaundice or liver disease?
Do you have a prosthetic or an artificial joint?
Do you have a bleeding problem or a bleeding disorder?
Have you ever been hospitalized for any illness or operations?
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Do you have or have you ever had any of the following?
Are there any conditions or disease not listed above that you have or have had?
Do you smoke or use tobacco products?
Are you nervous during dental treatment?

Patient Dental History

Have you been seeing a dentist regularly?
Do any of your teeth ache?
Have you ever been advised to take antibiotics before dental appointments?
Do your gums bleed when you brush?
Do you have any pain when you chew?
Do you feel that you have bad breath?
Have you ever been in a vehicle accident or experienced any trauma to your jaw?
Have you ever had any implant surgery?
Are you being followed-up by a dental specialist?
Do you have any problems with your jaw joint (pain, sounds, limited opening, locking, popping)?
Is there anything about the appearance of your teeth you would like to change?

Insurance Information

Emergency Contact

Clear Signature
I certify that the information I have given above is true to the best of my knowledge.

Your personal health information is protected by the Personal Health Information Protection Act (PHIPA) and is being collected only for the purpose of stated dental treatment herein. Your personal health information will only be used and disclosed as required or permitted by law. Access to your information will be limited to authorized healthcare providers and individuals involved in your care. By completing and submitting this form, you acknowledge that you understand the purposes for which your information is being collected and consent to its collection, use, and disclosure as described herein. You are within your rights to request that we not share the information in this form. Please inform a member of your health care team if you do not want your information shared with a health care provider. Please refer to the Personal Health Information Protection Act 2024 for more details.

Patient Information/Informed Consent Form

This information is provided to help you understand the treatment I am recommending. Before I move forward with any treatment, you should be well-informed and confident with the information provided to you. As such, information on potential treatments is outlined below. We will discuss these options together during our visit.
PLEASE BE SURE TO ASK ANY QUESTIONS YOU WISH. It's better to ask now than wonder about it after we start the treatment.

I am recommending some or all of the following dental hygiene treatments for you or your family member as indicated by client condition:

  • Complete oral examination and oral cancer screening.
  • Removal of dental plaque, tartar, and stain.
  • Placement of preventative fluoride and/or anti-microbial agents.
  • Placement of fluoride-releasing temporary fillings.

Some of the benefits of this treatment are:

  • Early identification of abnormal lesions or sore spots.
  • Reduced inflammation of the gums.
  • Cavity prevention or stabilization.

Some other risks of declining treatment are:

  • Failure to identify any oral health issues. If left untreated, this can lead to pain, infection, tooth loss, or other general health issues.
  • Forgoing preventative dental hygiene care may result in the onset and progression of gum disease, tooth loss, tooth decay, staining, and the progression of gingival infection.
  • Not filling a tooth with signs and symptoms of decay can result in increased sensitivity, pain, infections, tooth fracture, or loss.

I expect that it will take approximately 1-1.5 hours to complete the treatment, but be aware it could be shorter or longer based on what we experience as the treatment progresses.


Power of Attorney Name (if applicable)
Clear Signature
By signing above, I agree that I, being the patient or the power of attorney for the patient named above, have read this form in its entirety and understand the nature of the treatment I will be receiving, including risks and benefits. I permit iSmile Mobile Dental to access my medical/dental information and collaborate with any/all necessary healthcare providers to ensure that my health, safety, and dental needs are met. I also permit iSmile Mobile Dental to release information and communicate as necessary with my insurance company (if applicable) to assist in obtaining coverage for recommended procedures and submitting claims manually and/or electronically. iSmile Mobile Dental will handle all my information in compliance with current privacy legislation. I know that I am free to withdraw my consent at any time. I am aware that I am responsible for all billings related to this account and agree to pay invoices at the time of the treatment.