Adult Medical Health Questionnaire

This form will take several minutes and your progress can't reliably be saved for later if it's left unfinished. Before starting, please ensure you can complete it in one attempt. Your completed questionnaire will only be sent to us when you press the final Submit button.

We take security & privacy seriously. When you fill out this form online, your details will be stored in our secure database and will not be sent anywhere by email.

If you have any questions, please phone our office during regular business hours (found on this page).

Step 1 of 4

Patient Information

This helps us understand the best way to address you.

New patients are always welcomed with a smile!

You don’t need a referral from your dentist.

Get a complete consultation with Dr. Grubisa at no charge.

Not quite ready? Read more about becoming a patient.

online or by phone

Les nouveaux patients sont toujours accueillis avec le sourire!

Vous n’avez pas besoin de référence de votre dentiste.

Obtenez une consultation complète avec Dr. Grubisa sans frais.

Pas tout à fait prêt? En savoir plus sur comment devenir d’un patient.

En ligne ou par téléphone