Cedar Ridge Dental Patient Form/Covid Consent

Patient Medical History
Gender *

M F
Birthdate *

Day Month Year
Day Month Year
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Albert Health Care#AHC Treaty # Treaty
Insurance Information
   No insurance Insurance Has Not Changed Since My Last Visit
Primary Insurance Information:
Name of Insurance Company
Group/Policy number
IDnumber
Card Holder   name     birthdate

Secondary Insurance Information:
Name of Insurance   Company
Group/Policy   number
ID   number
Card Holder   name         birthdate
Health History
Have there been any changes to your general health, have you had major surgery or been hospitalized in the PAST YEAR? Answer below
Have you ever had a peculiar or adverse reaction to any medications or injections? Explain Below
Check all of the conditions that apply to you:

Anxiety Arthritis Asthma Autoimmune Blood Disorder Cancer/Tumors Diabetes Depression Dizziness/Fainting Epilepsy Excessive Bleeding Excessive Bruising Headaches Hard to Freeze Head or Face Injury Hearing Impaired Heart Murmer Hepatitis A, B, or C High Blood Pressure HIV Positive Kidney Disease Liver Disease Low Blood Pressure Multiple Sclerosis No Epinephrine Pace Maker Radiation Chemotherapy Rheumatic Fever Seizures Thyroid Disorder TMJ Tuberculosis Wheelchair
Check any that apply:

Heart Attack Heart Surgery Joint Replacement Stroke
If you answered yes to any of the above please select date it occurred

Day Month Year
Please list any medications you are currently taking.
Do you have an allergies to the following? *

NO Dental Anesthetics Aspirin Erthromycin Codeine Botox Latex Metals Penicillin Sulfa Tetracycline
Women Only:

Are you taking Birth Control Are you nursing Are you pregnant
ANNUAL CONSENT FOR TREATMENT AND PAYMENT

I AUTHORIZE and give consent to Cedar Ridge Dental to perform dental services agreed between the doctor and patient and/or parent/guardian deemed to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I certify that the above statements regarding my medical history and conditions are correct to the best of my
knowledge or that there have been no significant changes to my medical history in the past 12 months.

I UNDERSTAND that as a courtesy to me, CEDAR RIDGE DENTAL will direct bill my dental insurance. I hereby authorize payment directly to CEDAR RIDGE DENTAL from my group benefits. If my insurance pays me directly, I will be responsible for the total balance and will remit payment to CEDAR RIDGE DENTAL upon receipt. In the event that my insurance does not submit payment to Cedar Ridge Dental within 45 days, I will be forwarded the bill and be required to pay the entire balance owing and will collect reimbursement from my insurance directly.
Signature - Please sign with the mouse or fingertip *

Clear
Today's Date *

Day Month Year
Day -Month-Year
If the form won't submit for you, no worries, we do have forms available in office. Just arrive five minutes before your scheduled appointment to allow time to fill them out. We are striving to be a paperless office to limit contact but understand that there can be technical glitches at times. Thank you!
Should be Empty:

Patient Medical History

Insurance Information

Health History