Medical History Questionnaire

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

Please include city and post code.
Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.
(Name + Relationship)
PHONE
ADDRESS:
AREA OF SPECIALITY: PHONE AND/ OR ADDRESS:
AREA OF SPECIALITY: PHONE AND/ OR ADDRESS:

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.

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