www.lwdental.ca - New Patient Registration

Patient Name*

First NameMiddle NameLast Name

Birthday*

MonthDayYear

Age

Gender

Address*

Street Address

Street Address Line 2

CityState

Postal Code / APT#

Email Address*

example@example.com

Home phone #

Please enter a valid phone number.

Cell phone #*

Please enter a valid phone number.

Work phone #

Please enter a valid phone number.

Do you have a Previous dentist?*

YesNo

Are there any records or X-rays we should request from your previous dentist?*

YesNo

Previous dentist's name

Dentist address

Street Address

Street Address Line 2

CityState

Postal Code / APT#

Card Holder

Birthday

MonthDayYear

Insurance Co. Name

Group #

ID #

Employer

Do you have Secondary Insurance*

YesNo

Card Holder

Birthday

MonthDayYear

Insurance Co. Name

Group #

ID #

Employer

Patient Name*

First NameLast Name

Date of Birth*

Date

When was your last dental exam?

MonthDayYear

Dr.’s Name

When did you last have your teeth professionally cleaned?

MonthDayYear

Dental x-rays?

MonthDayYear

When was your last medical examination?

MonthDayYear

Family Dr. Name

How did you hear about us?*

Are there other health care professionals you see?*

YesNo

If "Yes" List them*

Can we notify them about today's findings to better treat your entire body's needs?*

YesNo

Is your health compromised? *

YesNo

Are you taking any medications now (baby aspirin etc.)?*

YesNo

If "Yes" Please list*

Are you taking any vitamins or herbal supplements? *

YesNo

If "Yes" Please list*

Serious illness, hospitalization, or operation in the last 5 years? *

YesNo

If "Yes" Please list*

Do you use tobacco or vaping products?*

YesNo

Amount*

Are you taking hormone medications?*

YesNo

Are you pregnant?*

YesNo

Are you taking hormonal birth control products?*

YesNo

Have you ever had any of the following*

Have you any allergies to the following?*

Do you have any other allergies/drugs?*

YesNo

If "Yes" Please List*

Do you have any disease, medical condition or problem not listed above?*

YesNo

If "Yes" Please List*

Are you nervous about visiting our office?*

YesNo

Are you in dental pain right now?*

YesNo

Do you have sensitive teeth?*

YesNo

What do you do every day to clean your teeth?

Other cleaning aids used & how often?

Do your gums bleed when you brush or floss?*

YesNo

Do you feel you have bad breath? *

YesNo

May we teach you our cure for flossing guilt?*

YesNo

Would you like to know when your teeth are clean enough?*

YesNo

Does your jaw get “stuck”, “locked”, or “go out”?*

YesNo

Have you ever injured your jaw, head or neck?*

YesNo

Do you ever have pain opening or closing your mouth?*

YesNo

Do you clench or grind your teeth?*

YesNo

Are you worried about the toxicity of your mercury (grey) fillings? *

YesNo

Appearance

Durability

Cost

Are you hard to freeze?*

YesNo

Have you ever had a reaction to local anesthetic?*

YesNo

Are you unhappy with the color of your teeth?*

YesNo

Are you missing any teeth?*

YesNo

Would you like your teeth to be straighter?*

YesNo

Would you straighten your teeth if you didn’t need to wear braces?*

YesNo

If you could change anything about your smile what would it be?*

Do you snore?*

YesNo

Do you fall asleep easily (while watching TV, during meetings etc.)?*

YesNo

Do you wake up most mornings not feeling refreshed?*

YesNo

We are committed to protecting the privacy of your personal information and to utilizing all personal information in a responsible and professional manner. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law. Common ways we use and collect personal information are listed below: Contact information is disclosed to third-party health benefit providers and insurance companies when a patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on their behalf. It is also used to invoice for dental services, collect unpaid accounts, or to remind patients concerning the need for further treatment. Financial information may be collected in order to make arrangements for the payment of dental services. Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. It may also be disclosed to other dentists and/or specialists for procedures to which Living Wellness Dental practitioners may choose to refer them. If selling all or part of our dental practice, qualified potential purchasers may be granted access to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

*

This is to certify that I consent to the dental procedures agreed to be necessary or advisable for myself or my child, including the use of local anesthetic or other drugs as indicated, and I will assume responsibility for fees associated with those procedures. I consent to the collection, use, and disclosure of my personal information as set out above.

Signature*

Clear

Name*

First NameLast Name

Date*

MonthDayYear

New Patient Registration

Insurance information

Primary Insurance

Secondary Insurance

Medical History

Women Only

Tell us about your oral health

Do you choose fillings based on? (Please list in order of importance the following 1 - More Important, 3 - Less Important)

Consent for Treatment & Privacy Disclosure