Yachna Dua D.M.D.

Manav Dua D.M.D.

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Best Dentist in Brampton
5 stars - based on 250 reviews

Smile Matters Dentistry

Brampton dentist provides affordable family dentistry services in Brampton, Mississauga, Caledon, Georgetown, Etobicoke, Bramalea, Bolton areas.
40 Gillingham Dr #407 Brampton, Ontario
Phone: 905-230-3200
905-230-3200 Hours:Mon-Fr 11am - 7:00pmMon-Thu 11am - 3:00pm
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Medical History Update


Smile Matters Dentistry

40 Gillingham Drive, Unit 407

Brampton, Ontario

L6X 4X7

Medical History Update

Patient Name:

Are you currently being treated for any medical conditions? YesNo

If yes, please list conditions:

Please name all medications/supplements:

Please list Any allergies:

Have you been hospitalized for any reason within the past 2 years? YesNo

If yes, please explain why:

Do you require antibiotics prior to dental treatment?YesNo

Do you smoke tobacco or marijuana or use any recreational drugs? YesNo

List any countries you’ve visited in the past 3 months:

Family doctor name & phone number:

Date of last physical exam by family doctor:

Please indicate if you are recently being treated for or experiencing any of the following conditions:

Cardiac stent placementCardiac bypass surgeryOrgan/valve replacement surgeryJoint replacementsKidney diseaseSleep ApneaLiver disease/ hepatitisHigh/low blood pressureDiabetesHeart AttackStrokeTrouble breathingAngina/chest painAnxiety/depressionAsthmaSwelling of ankelsBleeding/bruisingCancer/RadiationArthritisRheumatic heart diseaseTuberculosisHIV/AIDSEpilepsy

I, (print name), verify this information is accurate to the best of my knowledge.

Patient/ Guardian Signature:

Date:

Provider Signature:

Date :