New Patient Personal Information

New Patient Personal Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Cell Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email Address*
example@example.com
Emergency Contact:
Name
Full Name
Relationship
Contact Phone Number
Please enter a valid phone number.
Medical Doctor
Name
Phone Number
Please enter a valid phone number.
Last Medical Check up

MonthDayYear
Date
Pharmacy:
Pharmacy Name
Are you currently taking 2 or more medications?

YesNo
If yes, do you your give us consent to call your pharmacy for an updated med list:
Medication:
Medical History

Please check all that apply
Please check all that apply

Liver Disease (Hepatitis/Jaundice)Lung DiseaseChest PainMental or Nervous disorderStomach UlcersStrokeTuberculosisVenereal or Communicable DiseaseHeart or Circulatory problemsPace MakerRheumatic FeverAIDS/HIVAlcohol, chemical or Cannabis DependencyArthritis or RheumatismArtificial Joints or ValvesAsthma or Hay FeverBlood Transfusion Date:Cancer, Radiotherapy or ChemotherapyDiabetesEating DisorderEpilepsy / SeizuresFainting or Dizzy SpellsBlood pressure High OR LowGlycemia Hyper Or Hypo:Kidney DiseaseHeart DiseaseBlood test with unusual results?Persistent cough or cough of blood?Sexually Transmitted Infection?Thyroid Disease
Blood Transfusion Date:

MonthDayYear
Date
Have you ever had a reaction to any kind of medication? If yes, please specify
Have you ever had a rection to any kind of drug or local anesthetic If yes please specify
Have you ever had Rheumatic Fever, Heart Disease or replacement surgery?

YesNo
If yes, have you ever been told your require pre-medication?
Do you have any Allergies If yes please specify
Have you ever been hospitalized If yes please specify
Are you pregnant or nursing If yes please specify
Do you have any conditions or illnesses not listed above?

YesNo
If yes please specifiy
Dental History
Previous Dentist
Last Dental Visit
Please check all that apply

Bleeding gumsSensitive teeth Hot or ColdSensitive teeth Sweet or sourPain in your teethLumps or sores in your mouthHead, neck or Jaw InjuriesClicking in your jawJaw Pain (Joint, ear or side of face)Difficultly opening or closingDifficulty in chewingFrequent HeadachesDo you grind or clenchDo you bite your cheek/lip easilyArthritis or RheumatismArtificial Joints or ValvesEar Aches?Neck Ache?Does food get caught between your teeth?Have you ever had Periodontal (Gum) treatmentHave you had any difficult extractions in the past?Have you had prolonged bleeding following extractions in the past?Do you wear Dentures or partials? Placement date?Do you have any dental implants? Placement date?Have you had any orthodontic treatment?Have you ever seen a dental specialist?Do you have any loosening teeth?
Dentures or partials Placement date

MonthDayYear
Date
Dental implants Placement date

MonthDayYear
Date
Had any orthodontic treatment
Ever seen a dental specialist
You have any loosening teeth
Our Office Insurance Policies

Please Initial each one and sign at the bottom
Please Initial each one and sign at the bottom
- This office accepts direct payments from your dental plan for the cost of those dental services, which we may provide and which your plan covers. Fill Out (Initial)
- This office bases its fees on the current yearly fee schedule as recommended by the Alberta Dental Association and College. However, some plans are not on the current yearly fee schedule and you will be required to pay any difference. Fill Out (Initial)
- Dental plans in the marketplace are too numerous and varied to allow us to know the details of all of them. Therefore, you are responsible for knowing you plan details. Fill Out (Initial)
- Payments for any difference will be required on the same day as the appointment. If a payment plan is required, it MUST be arranged prior to your appointment. Fill Out (Initial)
Patient consent and acknowledgements

I, the undersigned, have completed the above questionnaire and/or update and that it is accurate to the best of my knowledge. I consent to the collection, use, retention, and disclosure of personal information required for my own (and/or my dependents) dental care. I certify that I consent to the performing of dental treatment and procedures agreed to be necessary or advisable. I also agree to assume responsibility for fees associated with those procedures. I understand that during the course of treatment, unexpected difficulties may arise, resulting in an altered prognosis, or a change of proposed treatment. I also consent to the taking of diagnostic photographs or radiographs agreed to be necessary. I further consent to be contacted by email, text and or telephone. I understand that all my appointments must be confirmed 24 hours prior and failure to do so will result in my appointment being removed from the schedule. I understand that less than 24 hours’ notice will be a short notice cancellation, after 2 short notice cancellations or no shows, my booking privilege will be revoked and I will require a $200.00 deposit to retain an appointment.
Patient Guardian Name
Patient / Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact:

Medical Doctor

Pharmacy:

Medical History

Dental History

Our Office Insurance Policies