Dr. Andrew Tortorella 289-271-0021
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4444 Drummond Rd.,

Niagara Falls, ON, L2E 6C6
Sleep Dentist for Kids/Adults
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289-271-0021

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Welcome to Dr. Tortorella's Office

REGISTRATION INFORMATION
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REGISTRATION INFORMATION

Your co-operation in completing this questoinaire is essential to providing you with the highest standard of dental care. All information is strictly confidential and will remaind with this office. Our receptionist is available to assist with the completion of this form.
This patient is an:(Required)
Name(Required)
Address(Required)
Reason for today's visit?(Required)
May we call you at work?(Required)
Prefers to be called:
MM slash DD slash YYYY
Are other family members patients at our office?(Required)
(if presently under care)
In case of emergency, please contact:(Required)
Nearest relative not living with you:

DENTAL HISTORY

Please check YES or NO to each question. If unsure of a question, please consult the dentist.
Is there a problem you would like treated immediately?(Required)
Date of your last dental visit?(Required)
Date of your last dental cleaning?(Required)
Date of your last x-rays?(Required)
Are you having regular dental visits?(Required)
Have you ever had any of the following:(Required)
Do your gums bleed when brushing, or eating or do you suffer from pain or swelling of your gums?(Required)
Does food catch between your teeth?(Required)
Are any of your teeth sensitive to heat, cold, sweets or pressure?(Required)
Have you ever experienced any of the following jaw problems?(Required)
Do you have any of the following habits?(Required)
Do you have any emotional concerns about having dental treatment?(Required)
Are you happy with the appearance of your teeth?(Required)
Have you ever had upsetting experience in a dental office, or any complications during or following dental treatment, or do you have any questions or concerns?(Required)

HEALTH HISTORY

Please check YES or NO to each question.
Are you being treated for any medical condition at present or within the past year?(Required)
When was your last visit to a physician?(Required)
Last complete physical examination?(Required)
Have you ever had any adverse or unusual reaction to any medications or injections? (e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic (dental freezing)"?(Required)
Have you ever been advised against taking any specific type of medication?(Required)
Do you have any allergies (e.g. hay fever, food allegies, latex/rubber or metal allergies)?(Required)
Have you ever fainted during dental or medical treatment?(Required)
Do you bleed excessively from a cut or injury, bruide easily or have any blood disorders?(Required)
Are you on cortisone, or steroid therapy, or, are you on a diet pill therapy?(Required)
Do you have any artificial joints (e.g. hip, knee)?(Required)
Have you ever been advised to take antibiotics before dental treatment?(Required)
Do you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic Fever?(Required)
Do you have, or have you ever had, any heart or blood pressure problems (heart or stroke)?(Required)
Do you have or have you ever had any chest pain, shortness of breath or any heart palpitation without exertion?(Required)
Are you presently suffering from any infectious disease?(Required)
Do you have any condition that could affect your immune system? (e.g. arthritis, AIDS, HIV Infection, lupus, inflammatory bowel disease. Chron's?)(Required)
Clear Signature
MM slash DD slash YYYY

Contact Niagara Falls Dentist

289-271-0021

Dr.Andrew Tortorella
Niagara Dentist

4444 Drummond Rd.
Niagara Falls, ON, L2E 6C6

Services

  • About Us
    • Meet the Staff
  • New Patient
  • Insurance
  • Book Appointment
  • Children
  • Services
    • Sedation Dentist
    • Sedation for Kids and Adults
    • Clear Braces
    • Veneers
    • Implants
    • Teeth Whitening
    • Crowns

 

 

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