Medical History Update

Medical and Dental History PDF

  • Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking could have an important interrelationship with the dentistry you receive. We thank you for your cooperation in answering the following questions.
  • Are you taking any medication, non-prescription drugs, or herbal supplements of any kind? If yes, please list below:

  • DOSE
  • Cancellation Policy: When you book an appointment with us, we reserve that time specifically with the dentist or hygienist. As such, we require two business days (48 hours) notice in the event an appointment must be changed or cancelled. This allows other patients awaiting treatment to be rescheduled in the slot initially reserved for you. Short notice cancellations (i.e. less than 48 hours’ notice) and no show appointments will be subject to a broken appointment fee, in the amount 40$, will be directly charged to the credit card on file. This fee will be used as a donation to sponsor a child through the CHEO Foundation. Life happens and we understand that sometimes you just can’t make it for a valid reason, in this case your card will not be charged for a first offence if it is for a valid reason. A Tax receipt for your donations will be given in February of the following year.
  • To the best of my knowledge the above information has been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any medical changes.



Call us now if you are experiencing a dental emergency,
we will respond swiftly and be happy to assist you.


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Copyright by DR. SARA SYED 2019. All rights reserved. Site by SKYFALL BLUE