Dr. Johnson Dental History Questionnaire

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Dr. Dexter Johnson M.D D.D.S F.R.C.D (C) Dip ABOMS

In order to provide safe dental care for our patients, we are asking you to fill out the following questionnaire. Please answer the questions as accurately as you can. If you have any questions or doubts, check the not sure / maybe choice. Your responses will be reviewed with you by the dentist. You can be assured that the information you provide will be kept in the strictest confidence.

NAME: MR./MISS/MRS./MS./DR. *

Telephone Numbers: *

Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.

Occupation:

Marital Status:

M S W D

In Case Of Emergency Notify: *

(Name + Relationship)

Emergency Contact Phone Number: *

Are You Covered By Any Type Of Dental Insurance?

Insurance (Group / Policy):

Policy Holder Date Of Birth:

ADDRESS (HOME): *

Please include city and post code.

Date Of Birth (DAY/MONTH/YEAR):

Place Of Business: *

Name Of Spouse:

Relationship:

Name Of Family Doctor:

Name Of Insurance:

Policy Holder:

Referred By Dentist:

Dental History

I the undersigned certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable including the use of local anaesthetic as indicated and I will assume responsibility for fees associated with these procedures.

Patient/Parent/Guardian Signature: *

Patients Over 18 Years Of Age.

Date / Time *

Message

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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Clinic HOURS:
Monday 7:30-7:30pm
Tuesday 7:30-3:30pm
Wednesday 7:30-3:30pm
Thursday 7:30-7:30pm
Friday 7:30-3:00pm

Clinic Closed: Dec 26/27 & 30

Open Dec 28 & Dec 29 7:30-2:00pm

Back to regular business Jan 2 2023 7:30-7:30pm.

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Address:
102-1500 Bank street Ottawa, Ontario K1H 7Z2
613-706-4101
Info@blueherondentalgroup.ca