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New Patient Form

Fill out the New Patients Form

Lundy's Lane Dental Office is always excited to welcome new patients and provide the dental help they need. We provide cosmetic dentistry, general dentistry, and sedation services at our dental clinic in Niagara Falls. You can book an appointment right away and visit our doctors. We would love if you could fill out the form given on this page, as it will provide us with more information about you and your medical history.

Fill out the form given below or download the form.

MEDICAL AND DENTAL HISTORY

Home ADDRESS

YES
NO

MEDICAL HISTORY: 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. PLEASE FILL IN THE ENTIRE FORM.

YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
CHEST PAIN
ANGINA
RHEUMATIC FEVER
LUNG DISEASE
STOMACH ULCERS
DRUG/ALCOHOL DEPENDENCY
HEART ATTACK
TUBERCULOSIS
ARTHRITIS
OSTEOPOROSIS MEDICATIONS
STROKE
CANCER
SEIZURE(EPILEPSY)
SHORTNESS OF BREATH
HEART MURMUR
STEROID THERAPY
KIDNEY DISEASE
PACE MAKER
DIABETES
THYROID DISEASE
ORGAN TRANSPLANT
MALIGNANT HYPOTHERMIA
MENTAL HEALTH DISORDER
YES
NO
YES
NO

FOR WOMEN ONLY:

YES
NO
YES
NO

DENTAL HISTORY

GOOD
FAIR
POOR
BLEEDING GUMS
CROOKED TEETH
COSMETIC
LOOSE TEETH
BAD BREATH
FOOD TRAPPING
SENSITIVE TEETH
TOOTHACHE
LOOSE DENTURES
MISSING TEETH/SPACES
WANT WHITER TEETH

PATIENT CERTIFICATION AND CONSENT

I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. Unless other arrangements are made payment is due at each office visit. Unpaid accounts may be subject to interest. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and the dentist. I authorize the dentist to treat me and I assume full responsibility of the fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.

Information

Lundy's Lane Dental Office
8123 Lundy's Lane, Unit #2

Orchard Grove Plaza

Niagara Falls, ON Canada, L2H 1H3

Phone: 905-371-8282

Hours

Monday: 9:00 AM – 5:00 PM
Tuesday: 9:00 AM -5:00 PM
Wednesday: 9:00 AM – 5:00 PM
Thursday: 11:00 AM -7:00 PM
Friday: 9:00 AM – 4:00 PM
Saturday: 9:00 AM – 3:00 PM

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