2022 New Patient Adult

PERSONAL INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth :*

DayMonthYear
Date
Gender
Referred By? (ie: Google, Walk By, Friend or Family Member Name)
How did you hear about us?*

Google SearchGoogle ReviewLive in AreaFamily/Friend ReferralDentist/Specialist ReferralOther
Please provide the name of the person or office who referred you.
Emergency contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
Please enter a valid phone number.
Dental Insurance Information (if applicable): Insurance Carrier Name
Dental Insurance Information: Subscriber Name & Birthdate
Dental Insurance Information: Relation to Subscriber
Dental Insurance Information: Policy / Plan/ Group #
Dental Insurance Information: Certificate or ID #
Alberta Health Care #*
Payment Options
Patients are responsible for payment of all dental services. All dental services are charged directly to the patient when treatment is rendered. For your convenience, we accept Debit, Visa & MasterCard. For patients with dental insurance coverage, we will assist submitting claim forms for your direct reimbursement.*
Note: it is the responsibility of the patient/insurance subscriber to understand the benefits & limitations of their dental coverage plan. Please initial indicating you have read the above.
Personal Information Disclosure Agreement
We are committed to protecting the privacy of our patients’ personal information & to utilizing all personal information in a responsible and professional manner. Patient personal information is collected and used for the purpose of updating personal profiles, invoicing, processing insurance claims, sending reminders and sending information to patients about out dental practice. Patient medical information is collected and used for the purpose of diagnosing dental conditions, treatment planning and providing dental treatment. Please initial indicating you have read the above.*
Cancellation Policy
Glamorgan Dental requires 2 business days notice to cancel or reschedule a reserved appointment. A $75 fee will apply to changes to reserved appointments with insufficient notice. Please initial indicating you have read the above.*
Mission Statement: Your Smile + Our Work = Together It’s Our Commitment for Better Oral Health! Our goal is to treat our patients based on their needs and wants for optimal dental and overall health. Each team member plays an important part in our success. Our satisfaction comes from patients who appreciate our efforts, care about their health and well-being and take responsibility for wanting the best level of care for themselves, their family and their friends.
INFORMED CONSENT
I, the undersigned, do hereby authorize and consent to the administration of all dental procedures deemed necessary or advisable for myself, or my child, by the attending dentist, including but not limited to, the use of local anesthetics or other prescribed medications. I shall assume the responsibility for payment of all fees associated with treatment procedures provided. I consent to collection, use and disclosure of my personal information for the purposes outlined in the personal information consent agreement. I have reviewed the foregoing information and consent. I have had the opportunity to ask questions and understand the above consent.
Patient Signature*

Clear
Date*

MonthDayYear
Date
DENTAL HISTORY
How would you rate the condition of your mouth?*

GoodFairPoor
Name of current or previous dentist.
Date of most recent dental exam.*
Date of most recent xrays.*
Date of most recent dental treatment.
Date of most recent dental cleaning.*
I routinely see my dentist every:

3 months4 months6 months12 monthsNot routinely
What is your immediate dental concern?*
Please select if any of the below apply.

Are you fearful of dental treatment?Have you had an unfavorable dental experience?Have you ever had complications from past dental treatment?Have you every had trouble getting numb or reactions to local anesthetic?Do you often feel tired, fatigued, have a hard time concentrating?Do you snore?Do you have sleep apnea?Have you ever had a sleep test or study?Is there anything about the appearance of your teeth that you would like to change?Have you ever whitened (bleached) your teeth?Are you self-conscious about yoru teeth?Have you been disappointed with the appearance of previous dental work?Do you have problems chewing gum?Do you have problems chewing bagels or other hard foods?Have your teeth changed in the last 5years, become shorter, thinner or worn?Are your teeth crowding, developing spaces or catching food?Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?Did you ever have braces or had your bite adjusted?Do you have any problems with sleep or wake up with an awareness of your teeth?Have you ever had any teeth removed?Do you have dentures or partial dentures?Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping?Do you have tension headaches or sore teeth?Do you wear or have you ever worn a bite appliance?Have you had any cavities withing the past 3 years?Do you have a dry mouth?Do you regularly breathe through your mouth?Are any teeth sensitive to hot, cold, biting or sweets?Have you ever had a tooth ache, cracked filling, broken, chipped or cracked tooth?Do you avoid brushing any part of your mouth?Do you fell or notice any holes(ie: pitting) in your teeth?Do you bite your nails or chew on objects with your front teeth?
Is your sugar intake?

LowModerateHigh
Where does your sugar come from?
Please select if any of the below apply.

Have you every been diagnosed or treated for periodontal (gum) disease?Have you ever experienced gum recession?Is there anyone with a history of periodontal disease in your family?Do your gums bleed when brushing, flossing or eating?Have you ever noticed an unpleasant taste or odor in your mouth?Have you experienced a burning sensation in yoru mouth>
How often do you brush your teeth?
How often do you brush your tongue?
How often do you floss?
Do you use any of the following?

Electronic toothbrushFloss aidsMouth rinseSpecialty toothpaste
MEDICAL HISTORY
Family Physician

First NameLast Name
Clinic Name of Physician
Date of recent medical physical examination
Please select if any of the below apply.

Anemia or blood disorderAnxiety/DepressionArthritisArtificial joints or heart valvesAsthmaAny lumps or swelling in the mouthBreathing or sleeping problemsChemotherapyDiabetesDigestive disorders (ie: gastric reflud)Dizziness or faintingEpilepsy/ convulsions or seizuresEmphysemaGlaucomaHeart murmurHead or neck injuriesHives, skin rash or hay feverHeart problems/conditionsHepatitis or JaundiceHormonal deficiencyHigh cholesterolHIV/AIDSHigh blood pressureHistory of strokeKidney diseaseLiver diseaseLow blood pressureMad cow disease, Gerstmann-Straussler-Scheinker disease or fatal familial insomniaNeurological problems (ie: memory loss)PacemakerProlonged bleeding after cutPsychiatric treatmentRheumatic fever or scarlet feverRadiation TherapyStomach problems (ie: ulcer)Shortness of breathTuberculosisTumor or abnormal growthThyroid or parathyroid diseaseViral infections & cold soresVenereal dieseaseAre you aware of changes in your general health?Are you on medication for osteporosis/ osteopenia?Are you subject to frequent headaches?Are you often exhausted or fatigued?Are you a smoker or smoked previously?Are you experiencing any lack of muscle coordination, dementia, twitches or tremors?Females-Are you taking any contraceptives?Females-Are you pregnant?MEN- Prostate disorders?Are you being treated for any other illness?Other
How would you rate your general health?*

GoodFairPoor
Please select if any of the below apply.

Hospitalization of illness or injury.Allergy to latexAllergy to aspirin, ibuprofen, acetaminophenAllergy to penicillinAllergy to erythromycinAllergy to tetracyclineAllergy to codeineAllergy to local anestheticAllergy to fluorideAllergy to metals (ie: gold, stainless steel)Other
Describe any current medical treatment, surgeries or other treatment that you are currently undergoing or will be undergoing:
Please list ALL medications, supplements and/or vitamins taken within the last 2 years.
Signature

Clear
Date

MonthDayYear
Date
Dental Sleep Medicine Screening
Dental Sleep Medicine is the management of sleep related breathing disorders, including snoring and obstructive sleep apnea (OSA). Sleep Apnea can pose significant health risks and affect your overall quality of life. Although OSA must be diagnosed by a certified sleep physician, dentists are in a unique position to screen for medical, physical and dental signs of sleep breathing disorders. In addition, certified dentists are able to offer treatments with Oral Appliance Therapy (OAT) to alleviate snoring and many cases of mild to moderate sleep apnea. Dr. Kreuz has continued her commitment to professional education in this important field and is proud to offer dental sleep medicine screening and Oral Appliance Therapy as a part of a whole health approach to her dental practice. Please complete the following screening questionnaire. Your health is important to us.
Name

First NameLast Name
Have you been diagnosed with a sleep disorder such as obstructive sleep apnea?

YesNo
If yes, when were you diagnosed?
What was the name of the clinic your study was completed?
Do you currently use a CPAP or an oral appliance to manage your sleep disorder?

YesNo
If yes, are you happy with your currenty therapy?

YesNo
If NOT, please explain
Please select any that applies to you.

Do you snore?Do you often feel tired, fatiuged or sleep during the daytime?Has anyone observed your breathing stop during sleep?Do you have or are you being treated for high blood pressure?Do you have a Body Mass Index (BMI) more than 35?Are you older than 50?Do you know if your neck size is greater than 16" in diameter?Was your gender at birth male?
Please select any that applies to you.

Difficulty falling asleepMorning headachesMorning hoarsenessFeeling tired and unrested in the morningFrequent waking during the nightsFrequent urination during the nightsSleep talking or walkingNight time grinding or clenching of teethFamily history of sleep apnea or snoringSnoringShort of breath upon waking (gasping)Heart racing upon wakingMouth breathingNight time congestionNight sweatsJaw clicking or painChronic cough or throat irritationWeight gainNeed caffeine during the day to functionDifficulty concentratingMoodiness/ IrritabilityHyperactivity
Do you have or had any of the following?

AllergiesAnxietyAsthmaADD/ADHDAtrial fibrillationChronic fatigue syndromeDiabetesDepressionDeviated septumFibromyalgiaGERD (gastric reflux)Heart disease/strokeHigh blood pressureHeart palpitations/ ArrhythmiaHistory of using a nightguardHistory of orthodontic treatmentHistory of tongue tie release at infancyInsomniaMetabolic syndromeSinus complications
Should be Empty:

PERSONAL INFORMATION

Payment Options

Personal Information Disclosure Agreement

Cancellation Policy

INFORMED CONSENT

DENTAL HISTORY

MEDICAL HISTORY

Dental Sleep Medicine Screening