Yachna Dua D.M.D.
Manav Dua D.M.D.
SMILE MATTERS DENTISTRY
40 GILLINGHAM DRIVE, UNIT 407
BRAMPTON, ONTARIO
L6X 4X7
At Smile Matters we care about our patients and their medical/dental health. It is our goal to provide the best possible treatment for you and your family. It is very important for us to know of any current changes (health/ dental) or developments including medications. Any information provided to our practice is kept private and is protected by doctor-patient confidentiality.
Name*:
Email*:
1. Have you travelled out of country the past month? If so where
2. Are you experiencing any fever, shortness of breath, cough? YesNo
3. Has there been any changes in your health, serious illnesses, allergies or hospitalization, since your last visit with us? YesNo
4. Are you taking any new medications or has there been any change in your medications? YesNo
5. Please provide a list of all medications.
6. When was your last medical check up?
7. Were there any problems identified
8. Is there anything we should be aware of?
Patient/Parent/Guardian Signature
Date
Dentist/Hygienist Signature
Provider Notes:
