4040 Finch Ave E, Suite 304

Scarborough, ON M1S 4V5

Tel: 416-292-8388

Email: drlam@on.aibn.com

Dr. Wai-man Lam & Associates

Dental care for the whole family - since 1997

Monday - Friday: 9:30 am - 7:00 pm

Saturday: 9:00 am - 6:00 pm                            

Sunday: 10:00 am - 6:00 pm

                                                                                             Copyright © 2013 by Dr. Wai-man Lam & Associates | website by ribeyeweb.com


Dr. Judy Tsai

Title

Phone #

First Name

Date Of Birth

Home Address

E-mail

Contact Phone #

preferred

Name

Who should we contact in case of emergency

When was your last dental xray?

Orthodontic treatment

Grinding/clinching

Toothache

Bleeding gum

Trauma to facial region

Teeth sensitivity

Need antibiotic before dental work

Do you have any allergies(drugs/foods)?

No

Yes

If yes please list

Do you have or have ever had any of the following? Please check.

Do you smoke or chew tobacco products?

No

Yes

How much?

Osteoporosis

Seizures

Rheumatic fever

Arthritis

Bleeding distorder

Thyroid disease

Tuberculosis

Steroid therapy

Stroke

Liver disease

Lung disease

Kidney disease

Aids or HIV

Hepatitis

Cancer

Drug or alcohol addiction

Do you have dental insurance?

No

Last Name

When was your last dental visit?

When was your last medical checkup?