4040 Finch Ave E, Suite 304
Scarborough, ON M1S 4V5
Monday - Friday: 9:30 am - 7:00 pm
Saturday: 9:00 am - 6:00 pm
Sunday: 10:00 am - 6:00 pm
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Dr. Judy Tsai
Trauma to facial region
Need antibiotic before dental work
If yes please list
High blood pressure
Aids or HIV
Drug or alcohol addiction
Diabetes - type I/II
Please list anything else:
To the best of my knowledge, all of the preceding answers and information provided
are true and correct. If
there is any change in health, I will inform the doctors at the next appointment
Do you have dental insurance?
Are you taking any medications, non-prescription drugs or herbal supplements of any
Please list anything else not mentioned above
When was your last medical checkup?
Who should we contact in case of emergency
Who should we thank for referring you to our office
Do you or have you ever had any of the following? Please check
Do you have any allergies(drugs/foods)?
Problems opening/closing mouth
Do you have or have ever had any of the following? Please check.
How often do you see your dentist?
Date Of Birth
Do you smoke or chew tobacco products?
Contact Phone #
When was your last dental visit?
When was your last dental xray?