(613) 395 – 2800 Dr. Lauren Allen | Dr. Ross Erwin | Dr. Nura Mazloom info@stirlingdentalcentre.com

Medical & Dental History Form

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 dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Medical & Dental History

  • MM slash DD slash YYYY
  • Emergency Contact

    In case of emergency, we should notify:
  • Medical History

  • Dental History