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Giving London the Gift of a Healthy Smile since 1994

New Patients Are Welcome at Westmount Family Dental

Westmount Family Dental welcomes new patients and values their time. Dr. Kim strives to streamline your visit so that your experience is comfortable and worth choosing him again. New patients are requested to fill the form below so that Dr. Kim can get familiar with their medical history. To fill up the forms at the office, try to arrive 15 minutes prior to your appointment. A friendly staff will be there to assist you in filling the forms. Schedule your appointment today!

Patient Form

London

Referral Information

Social Media
Search Engine
Lives in Area
Works in Area
Friend/Family
Patient Referral
Employee Referral
Yellow Pages
Other:

Patient Contact Information

Male
Female
Other

Name of Patient

Address

Home
Cell
Work
Single
Married
Common Law
Other

Insurance Information

Primary Insurance Company

Self
Spouse
Parent/Guardian

Secondary Insurance Company Information

Self
Spouse
Parent/Guardian
Other

Financial Information

Self
Spouse
Parent
Other

Name

Interac
Visa
Cash
Mastercard

Dental History

Sensitivity (hot, cold and/or sweet)
Tooth pain or discomfort while chewing
Headaches, earaches or neck pain
Jaw joint pain (clicking/cracking)
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, chipped or shifting teeth
Bad breath or bad taste in your mouth
Dentures
Orthodontics
Partial dentures
Periodontal (gum) treatments
Make your teeth brighter
Make your teeth straighter
Close gaps between teeth
Replace metal fillings with natural tooth coloured fillings
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Have a smile makeover
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Medical History

The following information is required to enable Westmount Family Dental to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

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chest pain, angina
rheumatic fever
pacemaker
steroid therapy
seizures (epilepsy)
heart attack
mitral valve prolapse
lung disease
diabetes
kidney disease
stroke, TIA
tuberculosis
stomach ulcers
thyroid disease
shortness of breath
heart murmur
cancer
arthritis
drug/alcohol/cannabis use or dependency
osteoporosis medications (e.g. Fosamax, Actonel)
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General Release

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Business Hours

Monday : 11:00 AM - 8:00 PM

Tuesday :  9:00 AM -6:00 PM

Wednesday : 9:00 AM - 7:00 PM

 

Thursday: 9:00 AM - 6:00 PM

Friday: 9:30 AM - 3:00 PM*

Saturday: 9:30 AM - 3:00 PM*

Sunday: Closed

*Varies depending upon the week. Please call for after-hours appointments.

Visit the Clinic

Address

Westmount Family Dental

925 Wonderland Rd S,

London, ON N6K 3R5

Methods of Payment

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