Medical Questionnaire (Part 1)

Required Fields *

Please fill in all required fields before continue.
Contact Information
Please fill in your first name.
Please fill in your last name.
Please fill in valid phone number.
Please fill in valid email address.

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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