YOUR TRUSTED PETERBOROUGH DENTIST

Whether you’re seeking information prior to a visit to our office or need further resources following a procedure, Lakeridge Dentistry has you covered. Below, we have provided forms for you to check out when you’re seeking information.


You may download, print and fill out the required forms or simply fill in the eForms below.

Lakeridge Dentistry

Male
Female
Telephone Home
Telephone Work
Cell Phone
Email

DENTAL HISTORY

Lakeridge Dentistry

Excellent
Good
Fair
Poor
3 months
4 months
6 months
12 months
Not routinely

PERSONAL HISTORY

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

SMILE CHARACTERISTICS

Yes
No
Yes
No
Yes
No
Yes
No

BITE AND JAW JOINT

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

TOOTH STRUCTURE

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

GUM AND BONE

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

MEDICAL HISTORY

Lakeridge Dentistry
Excellent
Good
Fair
Poor

DO YOU HAVE or HAVE YOU EVER HAD

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

ARE YOU:

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Copyright Lakeridge Dentistry 2018 - Legal
Created by

Legal notice