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Our Team
Treatments
Gallery
Forms
Blogs
Contact

Home
Our Team
Treatments
Gallery
Forms
Blogs
Contact

Home
Our Team
Treatments
Gallery
Forms
Blogs
Contact

Request Appointment

Botox/Dysport Consent

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1Patient Information

2Medical History

3Submission

Patient Information

Name *

First

Last

Date of Birth *

Sex

Female
Male

Address

Address (copy)

City

State / Province / Region

Postal / Zip Code

Country

Mobile

Home Phone

Email *

How did you hear about our clinic?

Doctor's referral
Family/Friend/current patient
Attended seminar/ trade show
Newspaper
website/Internet
Coupon
Yellow Pages
Magazine
Walk by
Other

Other

I am interested in (please check all that apply)

Botox cosmetic
Enhancing and defining lips
Cosmetic fillers temporary
Treatment of age spots/sun damage
Skin rejuvenation/Wrinkle reduction
Cosmetic dental smile makeover

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The doctor will review the questions and explain any that you do not understand. Please fill in the entire form.

Please check the appropriate condition for which you have ever been treated for

Acne
Hormonal imbalanc
Hirsutism
Cancer (or radiation therapy)
Shingles
Port wine strain
Arthritis
Polycystic overian syndrome
Skin pigmentation
Psoriasis
Autoimmune disorder
Keloid scars/ other scars
Steroid or hormonal therapy
Local anesthetic sensitivity
Blood disorder
Herpes (or cold sores)

Do you use sunscreen?

Yes
No

What SPF?

When you sunbathe, how does your skin respond?

Family physician

Drug allergies

Medication

Please list any past illnesses or surgeries:

Illness or Surgery

Are you currently taking any medications (including aspirin, birth control, herbal medications,etc?

Yes
No

(copy) breast how

Medications

Medication

Purpose

Do you smoke?

Yes
No

How many per day?

Weight

Height

Are you currently being treated for any condition not listed?

Yes
No

Please specify

Have you ever used or currently using Vitamin A or Glycolic acid?

Yes
No

Please specify

Have you ever used or currently using Accutane?

Yes
No

Please specify

Have you ever had a chemical peel?

Yes
No

Please specify

Have you ever had laser treatment?

Yes
No

Please specify

When was the last time you waxed the area to be treated? (copy)

When was the last time you used depilatory on the area to be treated?

What products are you currently using on your skin?

Do you have any particular skin sensitivities?

Have you ever been treated by an Endocrinologist?

Yes
No

Please specify

Do you sunbathe or use self tanning lotions or use tanning besd?

Yes
No

Please specify and how often?

Are you currently pregnant, breast feeding or do you plan to become pregnant in the next year?

Yes
No

Please specify

Signature

I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician or pharmacist being contacted if necessary to obtain information that is required for my dental care.

Patient Signature *

Clear Signature

Date

Our Office

Our modern and growing dental care facility is located in Pitt Meadows. Our entire team is dedicated to providing you with personalized, gentle care. Our dentists are not only caring and compassionate, but highly trained in all aspects of dentistry. We strive to deliver the best care possible, while making your visit both a soothing and serene experience. We are open on Saturdays and provide Emergency care for your dental needs.

Schedule an appointment today

Book an Appointment

Meadows Gate Dental is committed to providing gentle, personalized dental care for the whole family. From routine cleanings to advanced cosmetic treatments, we help you smile with confidence in a welcoming environment.

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Contact

12099 Harris Rd, Suite 310,
Pitt Meadows, BC V3Y 0E5

info@meadowsgatedental.ca

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