New Patient Registration Form
Information provided will be kept confidential
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Email Address
*
example@example.com
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cellphone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Physician/Doctor's Name
Doctor Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Relationship to Patient
Emergency Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Whom may we thank for referring you?
Relationship to Patient
If not, how did you hear about us?
Please Select
Drive-By
Walk In
Internet Search (Google)
Friend
Relationship to Patient
DENTAL HISTORY
Reason for Visit
*
Please Select
Toothache
Chipped tooth
Knocked tooth out
Broke tooth
Abscess
Swelling
Dentures
Other
Tell us the reason for your visit
*
Last dental visit?
*
Name of your current dentist
*
X-Rays taken last 12 months?
*
Yes
No
Have you had any complications or difficulty with previous dental treatment?
*
Please Select
Yes
No
Please explain
*
How do you rate yourself as a dental patient?
*
Please Select
Calm
Slightly Nervous
Very Anxious
Back
Next
MEDICAL HISTORY
Are you currently in good health? If no, please explain.
*
Yes
No
Please explain.
Are you under the regular care of a physician (other than regular check-ups)?
*
Yes
No
Please explain.
Have you ever had a serious illness or operation? If yes, please explain
*
Yes
No
Please explain.
Do you currently have or ever had any of the following conditions? Please SELECT all those that apply
*
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Contraceptive Use
Diabetes
Emphysema
Epilepsy
Excessive Bleeding
Excessive Bruising
Gasto-Intestinal
Glaucoma
Hay Fever
High Blood Pressure
Head Injury
Hearing Disabled
Heart Disease
Heart Murmur
Hepatitis A B C
HIV + (AIDS)
Jaundice
Kidney Disease
Low Blood Pressure
Liver Disease
Psychiatric Care
Multiple Sclerosis
Nervous Disorders
Pacemaker
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Sinus Problems
STD
Stomach Problems
Stroke
Thyroid Disease
Tuberculosis
Tumors
Ulcers
None of the above medical conditions
High Blood Pressure
Are you allergic to or ever had a reaction to any of the following?
*
Aspirin (ASA)
Codeine
Local Anesthetic
Penicillin
Sulpha Drugs
None
Other
Do you smoke?
*
Yes
No
Have you had a persistent cough for the last 24 hours?
*
Yes
No
Women: are you pregnant?
Yes
No
How many weeks?
Any other physical conditions of which the doctor should be aware of?
*
Please Select
Yes
No
Please explain
*
Are you currently taking any medications or vitamins?
Please Select
Yes
No
If yes, please list
*
Do you have insurance?
*
Please Select
Yes
No
Primary Insurance Information
Policy Holder First and Last Name
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Insurance Provider
*
Group Plan #
*
Certificate or Subscriber ID #
*
Do you have secondary insurance?
*
Please Select
Yes
No
Secondary Insurance Info
If applicable
Policy Holder First and Last Name
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Insurance Provider
*
Group Plan Number #
*
Certificate or Subscriber ID #
*
To qualify for assignments of benefits, we will require the following:
We do not accept assignments Alberta Works (Aish) and Treaty.
Do you have a credit card to leave on file?
*
Yes
You are aware you are responsible for the total fees regardless of what insurance may or may not cover or estimates:
*
Yes
Estimated uninsured portions are paid at the time of service:
*
Yes
All balances are subject to 2% interest per month:
*
Yes
Signature
*
Submit
Should be Empty: