4040 Finch Ave E, Suite 304
Scarborough, ON M1S 4V5
Monday - Friday: 9:30 am - 7:00 pm
Saturday: 9:00 am - 6:00 pm
Sunday: 10:00 am - 6:00 pm
© 2013 by Dr. Wai-man Lam & Associates | website by ribeyeweb.com
Dr. Judy Tsai
Date Of Birth
Contact Phone #
Who should we thank for referring you to our office
Who should we contact in case of emergency
When was your last dental xray?
How often do you see your dentist?
Do you or have you ever had any of the following? Please check
Problems opening/closing mouth
Trauma to facial region
Need antibiotic before dental work
Do you have any allergies(drugs/foods)?
If yes please list
Do you have or have ever had any of the following? Please check.
Do you smoke or chew tobacco products?
High blood pressure
Aids or HIV
Drug or alcohol addiction
Diabetes - type I/II
Please list anything else:
To the best of my knowledge, all of the preceding answers and information provided
are true and correct. If
there is any change in health, I will inform the doctors at the next appointment
Do you have dental insurance?
When was your last dental visit?
Are you taking any medications, non-prescription drugs or herbal supplements of any
Please list anything else not mentioned above
When was your last medical checkup?