Medical Questionnaires

Medical Questionnaires

Do you have dental insurance?
Do you have secondary insurance?
Dental Concerns (Check all that apply)
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 a sedation in a dental office?
Past and Current Conditions (check all that apply to you, now or in the past)
Cardiovascular
Pulmonary
Endocrine
Other Conditions
Are you allergic, or have you had any unusual reaction to any of the following?
Prostheses

Contact Us

Dr. Gabriel Lacombe
Village Walk Family Dental
Suite #100, 200 Villagewalk Boulevard
London, ON
N6G 0W8

Note: Please direct all inquiries to Lauren Charman BSc RRT, Anesthesia Treatment Coordinator – 519-930-3341


Fax: (519) 681-9176
Email: drlacombe@lsdental.ca

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