(519) 930-3341

Medical Questionnaire

Referring Dentist Infomation
Patient Information
Patient Information
Dental History
Dental Concerns
Medical History
If you have health conditions involving any part of your body, this may have a relationship with your dental health and could influence the type of dental care and the way we administer your sedation. You are helping us provide you with the best possible care by completing this questionnaire as carefully as possible.
Have you ever had sedation in a dental office?
Medical Conditions
Past and Current Conditions (check all that apply to you, now or in the past)
Cardiovascular
Pulmonary
Endocrine
Other Conditions
Medical History Continued
Are you allergic, or have you had any unusual reaction to any of the following?
Prostheses

At Lacombe Sleep Dentistry, we’re more than just a dental practice— we’re a place where your comfort and care come first. Our experienced team is committed to delivering top-notch dental services in a relaxed, friendly environment. Whether you’re here for a routine check-up or a more specialized procedure, we’re here to make sure you feel at ease every step of the way.

Get In Touch

© 2025 Lacombe Dentistry. Powered by Amity Technologies.

Lacombe Dentistry

Contact

Menu

Have a question?

Fill out the form below, and we will be in touch shortly.