Dr. Gita Mehrabani, DDS | New Patient Form

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(514) 696-5745

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New Patient & First Appointment Form

The following information is required in order to complete our records and to enable us to give proper consideration to your treatment needs. This form is strictly confidential. Please fill out the form completely. Please allow yourself approximately 10 minutes to complete the form.

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Personal Information
Greeting*
- Mr.
- Mrs.
- Ms.
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Home or Main Telephone Number*
Best Time to Call*
Mobile or Other Telephone Number
E-mail
Date of Birth*
Quebec Medicare Card Number
Whom may we thank for referring you to our practice?
Would you like to book an appointment?*
- Yes
- No
- I already have/requested an appointment
Appointment & Availability Information
For emergencies, call (514) 696-5745.
How can we help?
Weekday Availabilty*
Select all that apply
- Monday
- Tuesday
- Wednesday
- Thursday
Weekday Availabilty*
Select all that apply
- 9 AM - 11 AM (Tuesday & Thursday)
- 11 AM - 1 PM
- 1 PM - 3 PM
- 3 PM - 5 PM (Except Thurday)
- 5 PM - 7 PM (Monday & Wednesday)

Occupation and Insurance
Occupation
Are you employed?*
- Yes
- No
Employer Name*
Employer Telephone Number
Employer Address
Street Address Address Line 2 City Province Postal Code
Do you have Dental Insurance?*
- Yes
- No
If yes, Insurance Company Name*
Policy Number*
Group Number*

Medical History
Are you in good health?*
- Yes
- No
Date of last medical examination
Are you under the care of a physician?*
- Yes
- No
Name of your physician*
Physician Address
Street Address Address Line 2 City Province Postal Code
Have you ever had a serious illness or operation?*
- Yes
- No
If yes, please elaborate*
Do you or have you ever had any of the following diseases or problems?*
- No known diseases or problems
- Rheumatic fever or rheumatic heart disease
- Heart problems
- Cardiovascular disease (chest pain, shortness of breath, swollen ankles)
- Allergies
- Asthma
- Hives or skin rash
- Fainting spells, Dizziness, or Seizures
- Diabetes
- Hepatitis, Jaundice, Liver disease
- Arthritis
- Stomach ulcers, Digestive or Gastrointestinal problems
- Kidney ailments
- Lung problems (difficulty breathing, persistent cough)
- Venerial Disease
- Bleeding Problems
- Anemia
- Frequent colds or sinusitis
- Visual disorders (Cataract surgery, glaucoma)
- Thyroid problems
- Nervous disorders
Have you ever had surgery or X-Ray therapy for a tumor or growth?*
- Yes
- No
Are you taking any drugs or medication?*
- Yes
- No
If yes, please elaborate*
Are you allergic to, or have you reacted adversely to any drugs, food, or medication?*
- No known allergies to drugs, food, or medication
- Penicillin
- General anesthesia
- Sulfa / Sulfa-based
- Aspirin
- Iodine
- Dyes
- Other...
If other, please let us know what*
Have you ever had any trouble associated with dental treatment?*
- Yes
- No
If yes, please elaborate*
Do you have any disease, condition, or problem not previously mentioned that we should know about?*
- Yes
- No
If yes, please elaborate*
Are you pregnant or nursing?*
- Yes
- No

Dental History
Date of last dental visit
Have you ever been shown how to properly brush and floss?*
- Yes
- No
Are you satisfied with the appearance of your teeth?*
- Yes
- No
If not, please elaborate*
Are you bothered by...
- Bad breath
- Loose teeth
- Missing teeth
- Teeth that have shifted position
- Bleeding gums
- Sensitivity to hot
- Sensitivity to cold
- Sensitivity to sweets
Can you chew adequatley?*
- Yes
- No
Do you clench or grind your teeth?*
- Yes
- No
Have you ever had...?
- Gum treatments
- Bite adjustments
- Crowns / Caps
- Bridges
- Root canal treatment
- Dentures
- Orthodontic treatment
Are you satisfied with your past dentistry?*
- Yes
- No
If not, please elaborate*
Have you ever had any bad dental experiences?*
- Yes
- No
If yes, please elaborate*
What concerns you most about going to the dentist?*
What could we do to make your dental visit as pleasant as possible?*
Do you have any other concerns, comments, or suggestions?

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