Additional Form – Dr. C.P. Giri dentistry

Dr. C.P. Giri dentistry

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Call: (905) 770 2006
Call: (905) 770 2006

Registration Form

1. Has there been any change in your health, such as serious illnesses, hospitalizations or new allergies?

Yes No

If yes, please specify.

Blood pressure SYS

Blood pressure DIA

Pulse

2. Are you taking any new medications or has there been any change in your medications?

Yes No

If yes, please specify.

Have you been screened at a Covid 19 testing center?

Yes No

If so what was the outcome positive or negative?

Please take the self assessment covid 19 (novel coronavirus).

What was the result of the self assessment?

3. Have you had a new heart problem diagnosed or had any change in an existing heart problem?

Yes No

4. When was your last medical checkup?

5. Were any problems identified?

Yes No

If yes, please specify.

6. For women only: Are you breastfeeding or pregnant?

Yes No

If pregnant, what is the expected delivery date?

Signature

Date

Response Date

3758

Youe first Name

Your Last Name

Phone Number

Your Email *

Please take the self assessment covid 19 (novel coronavirus). What was the result of the self assessment? (Assessment must be done within 48 hours before the dental appointment)

Have you been screened at a Covid 19 testing center?

If so what was the outcome positive or negative?

1. Has there been any change in your health, such as serious illnesses, hospitalizations or new allergies?

If yes, please specify. (copy)

Blood pressure SYS

Blood pressure DIA

Pulse

2. Are you taking any new medications or has there been any change in your medications?

If yes, please specify.

3. Have you had a new heart problem diagnosed or had any change in an existing heart problem?

4. When was your last medical checkup?

5. Were any problems identified?

If yes, please specify.

6. For women only: Are you breastfeeding or pregnant?

If pregnant, what is the expected delivery date?

Signature

Date

Email *

577623758

Clinic Hours

Tuesday: Appointment Only
Wed - Fri: 10.00AM - 7.00PM
Alternative Saturday: 9.00AM - 3.00PM
Sun - Mon & Alternative Thursday: Closed

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Appointment
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Contact

Get In Touch

9791 Bayview Avenue,

Richmond Hill,
Ontario, L4C 9X7

Tel: (905) 770 2006

Dental Emergency: 416 485 7121 / 416 919 9911

Fax: (905) 508 7887

info@Drcpgiri.com

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