Patient Information

The following information is required by Modern Smiles to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Medical History

Specific History

Do you, or have you had, any of the following:

Dental History

Complete the following questions if you have a denture or partial.


I the undersigned hereby certify that all of the medical and dental information provided on this form to be true to the best of my knowledge and that I have not knowingly omitted any information. I also consent to my family physician/family dentist being contacted, if necessary, to obtain further information or clarification of medical/dental conditions as is necessary for my denturist treatment.

I hereby assign my benefits, payable from claims submitted electronically, to Rae-Lynne Robichaud and authorize payment to her. This authorization shall continue in effect until the undersigned revokes the same.