New Patient Form | Complete Your Dental and Medial History Form

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- Dr. Israa Al-Ani
- Dr. Mustafa Alani
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Waterloo Dentist

We understand that trying to find a nearby dentist you can trust is difficult, that is why we make it easy for you to work with us.

225 - 50 Westmount Rd N

dentalwestmount@gmail.com

(519) 578-2720

HOME
ABOUT
- Dr. Israa Al-Ani
- Dr. Mustafa Alani
PATIENT INFORMATION
DENTAL TREATMENTS
DENTAL PROCEDURES
PEDIATRIC DENTISTRY
CONTACT

New Patient Form

Records Release Form

Medical Questionnaire

Office Policy Form

Patient Information

Patient Information

First Name

Last Name

Email

Phone Number

Date of Birth

How did you hear about us?

Emergency Contact Name

Emergency Phone Number

Emergency Relationship

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Address

Address

Street Address

Unit

City

Province

Postal Code

Country

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Insurance Information

Insurance Information

Do you have dental insurance?

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If yes, please complete the following questions. If no, move onto Medical History

If yes, please complete the following questions. If no, move onto Medical History

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Insurance Company Name

Certificate / ID Number

Policy Number

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Medical History

Medical History

Family Physician Name

Family Physician Number

Date of last doctor visit

Previous Dentist Name

Previous Dentist Number

Date of last dental visit

Have you had dental x-rays taken within the last 2 years?

Do you have any of the following illnesses

Heart disease

High blood pressure

Low blood pressure

Hepatitis A/B/C

Drug addiction

Cold sores

Oral cancer

Have had radiation or chemotherapy

HIV or AIDS

Other sexually transmitted disease

Epilepsy or seizures

Tuberculosis

Diabetes

Stroke

Jaundice

Asthma

Sinus trouble

Snoring

Thyroid disorder

Arthritis

Digestive disorder

Kidney disease

Gastrointestinal disorder

Bleeding disorder or bruise easily

Do you have any of the following conditions

Facial muscle tenderness

Jaw joint clicking, popping, or locking

Migraines or headaches

Earaches

TMJ (jaw pain)

Neck or shoulder pain

Hearing loss

Lumps or sores in your mouth

Teeth grinding

Sore or tender gums

Snoring

Burning sensation on your lips or tongue

Sleep apnea

Dry mouth

Do you smoke

Do you suffer from any illness or condition not listed? (please list)

Are you allergic to latex?

Are you allergic to metals?

Are you allergic to acrylic?

Please list all medications you are currently taking

Please list all major injuries and surgeries in the last 10 years

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Opt-In

I hereby certify that all of the information in this form is true to the best of my knowledge and that I have not knowingly omitted any information. By checking, I agree to share my form responses.

Thank you for completing our New Patient Form.

Our office will review your form and reach out to you if we have additional questions. We may try to contact you before your scheduled appointment to confirm some of your answers.

Please note: if this is a dental emergency, it is best to call our office as this is the quickest way to reach us (519) 578-2720

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Waterloo Dentist

We understand that trying to find a nearby dentist you can trust is difficult, that is why we make it easy for you to work with us.

225 - 50 Westmount Rd N

dentalwestmount@gmail.com

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PATIENT INFORMATION
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PEDIATRIC DENTISTRY
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Dental Clinic Hours

Monday: 9:00 am - 5:00 pm
Tuesday: 9:00 am - 5:00 pm
Wednesday: 11:00 am - 7:00 pm
Thursday: 9:00 am - 5:00 pm
Friday: 9:00 am - 5:00 pm
Saturday: Closed
Sunday: Closed

© 2026

All Rights Reserved | Westmount Dental

© 2026

All Rights Reserved | Westmount Dental

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