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Medical Questionnaire (Part 1)

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Contact Information
Please fill in your first name.
Please fill in your last name.
Please fill in valid phone number.
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Patient Information

Gender *

Please select your gender.

Date of Birth *

Please fill in valid year of birth.
Please fill in dentist's name.

Health Benefit Information (check all that apply)

Are you covered by a government sponsered program?

You must present the current month ODSP Dental Card (or a photocopy) to every dental appointment. Dr Lacombe will not see you without these documents.


Referral Information

Where did you hear about our practice?


Contact us

  • Dr. Gabriel Lacombe
  • Village Walk Family Dental
  • Suite #100, 200 Villagewalk Boulevard
  • London, ON
  • N6G 0W8
  • Phone: (226) 636-2222
  • Note: Please direct all inquiries to the anaesthesia manager, Shayma
  • Fax: (519) 681-9176
  • Email: drlacombe@lsdental.ca
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