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Ilderton Dental Care

Patient forms

Complete your forms online

Registration, dental history, medical history and consent in one secure form. It takes about 10 minutes.

Your answers are encrypted when sent and stored securely. Only clinic staff can see them. Read our privacy page. Prefer paper? Download the PDFs or call (519) 914-5355.

If you have tooth pain, swelling or an urgent concern, don't use this form. Call us, or 911 in an emergency.

1. About you

Name and phone

For example your insurer's name, or CDCP. Bring your card to your visit.

2. Dental history
3. Medical history

Your dentist uses this to keep your care safe. Answer what you can; we'll go over it with you at your visit.

Include prescriptions, blood thinners and supplements.

For example penicillin, latex or local anaesthetic.

Do you have, or have you had, any of these? (optional)
4. Consent

Consent for any treatment is discussed and signed with your dentist at the clinic.

Call (519) 914-5355
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