• New Patient

    New Patient

  • Tooth Works Dentistry would like to welcome you to our dental practice.

    In your new patient exam, we will examine your teeth, gum tissue, the function of your jaw joint, obtain a digital scan of your teeth and perform an oral cancer screen. Together we will discuss our findings and develop a treatment plan.

    We are happy to help you submit dental claims to your insurance. If dental claims do not specify amount payable to our practice on day of treatment, you will be responsible for the payment. We accept Visa, MasterCard, American Express, Debit.

    Please complete the attached personal information/medical history, consent form; bring them to your first visit. If you have dental benefits, please bring your coverage information with you and to this initial visit as well.

    Your appointment times are reserved for you exclusively. We require 48 hours cancellation. We also realize your time is valuable and promise to do our best to be on time for your appointments.

    Parking is available for all our patients in the Impark parking lot located South of the Petroleum building (just North of the Legislature on 109 street). Stalls have been marked with a “Tooth Works Dentistry” sign. Once you arrive in our office, be sure to let one of our team members know to sign in your vehicle with your license plate number.

    You will receive an email with a COVID-19 questionnaire. We ask you to fill out the form at least 24 hours prior to your appointment.

    If you have any questions or concerns, or require further information please do not hesitate to contact us at 780-428-7830 or info@toothworksonline.com

    We look forward to meeting you!

  • PERSONAL INFORMATION CONSENT FORM

  • We are committed to protecting the privacy of your personal information and to using it in a responsible and professional manner.

    Personal information is used to open and update patient files, to contact patients for follow-up treatment and to process dental benefit claims. We also contact patients about relevant changes or updates within our practice.

    Financial information is used to process payments for our services, to process claims for third party providers/dental insurance companies and collect unpaid accounts.

    Medical and dental information is used to diagnose and treat dental conditions, safely and appropriately.

     

  • Billing Procedures

  • Our office offers assignment of benefits for your insurance carrier(s If your insurance does not respond, those benefits will be assigned to the patient. Services will be paid in full for each visit.

    We will prepare all necessary reports to help collect any benefit from your insurance. Our fees are not based on the insurance company fee guides.

    I consent to the collection, use and disclosure of my personal information as indicated above.

  • Date*
     / /

  • PERSONAL INFORMATION

  • Date of Birth (DD/MM/YYYY)*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • In Case of Emergency

  • Format: (000) 000-0000.
  • Do you have insurance?*

  • Insurance Information

    Primary
  • Date of Birth (DD/MM/YYYY)*
     / /
  • Do you have secondary insurance?*

  • Insurance Information

    Secondary
  • Date of Birth (DD/MM/YYYY)*
     / /

  • MEDICAL HISTORY QUESTIONAIRE

  • The following information is required to enable us to provide you with the best possible dental care.
    All information is confidential. Please fill in the entire form.

  • Are you currently being treated for any medical condition?*
  • Have you been hospitalized recently?*

  • Are you taking any medications, non-prescription drugs or herbal supplements? If yes please list.

  • Do you have any allergies?*
  • Have you ever had any unusual reactions to local anesthesia (freezing) or medications?*
  • Do you have asthma or do you use an inhaler daily?*
  • Do you have or have you ever had any heart or blood pressure problems?*
  • Do you have any joint replacements?*
  • Do you require premedication prior to dental treatment?*
  • Do you have any conditions or therapies that could affect your immune system?*
  • Have you ever had hepatitis, jaundice, or liver disease?*
  • Do you bruise easily or bleed abnormally?*
  • Do you have or have you ever had any of the following?*
  • Do you have a family history of any diseases or medical conditions?*
  • Do you use tobacco products?*
  • If yes are you interested in quitting?*
  • Do you use marijuana or recreational drugs?*
  • Are you nervous during dental treatment?*
  • For women only: Are you pregnant or breast-feeding?

  • DENTAL QUESTIONAIRE

  • Would you like to improve your smile?
  • Would you like to improve the alignment of your teeth?
  • Do you have any missing teeth that you would like replaced?
  • Do you wear dentures?
  • Do you have any dental implants?
  • Do you currently experience any pain or sensitivity with your teeth?
  • Do your gums bleed when you brush and floss?
  • Are you aware of teeth clenching/grinding, cheek/nail biting, lip biting or mouth breathing?
  • Do you have a night guard (splint)?
  • Do you use a CPAP machine or snore appliance?
  • Do you have any jaw (TMJ) problems?
  • Date*
     / /
  •  
  • Should be Empty: