• Medical/Dental History

  • Patient Information

  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of contact?*
  • Adult Patient*
  • Child Patient*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • In Case of Emergency, we should notify:
  • Format: (000) 000-0000.

  • Primary Insurance Information

  • Insurance Coverage*
  • Policy holder's date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Secondary Insurance Information (If Applicable)

  • Insurance Coverage
  • Policy holder's date of birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Dental Information

  • Deer Valley Dental - Suite 112, 200 Awentia Drive, Leduc, AB, T9E 0C4

  • 780-900-2283

  • 2. Have you been seeing a dentist regularly?*
  • 5. Are you happy with your smile?*
  • 6. Do you have/ had anything listed below:*

  • Medical Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 1. Do you visit your family Physician Regularly?*
  • 3. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
  • 4. Do you use any of the following?
  • 5. Have you experienced any unusual reactions to the following?
  • 6. Do you have any allergies?*
  • 7.Do you have any of the following diseases or conditions? (When given an or option, please circle the one that pertains to you)*
  • Deer Valley Dental - Suite 112, 200 Awentia Drive, Leduc, AB, T9E 0C4

  • 780-900-2283

  • 10. Are there any other medical problems we should be aware of?

  • 11. WOMEN ONLY -

  • Are you: Pregnant?*
  • Nursing?*
  • Taking Birth Control Pills?*

  • General Release

  • I the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and I have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical/dental history. Should there be any change in my health status in the future, I will advise this dental office, I authorize the dentist to perform diagnostic procures as may be required to determine necessary treatment.

  • Personal Information Consent

  • The personal, medical, and financial information that we collect are used for the following purposes:

    • To open and update patient files.
    • To invoice patients for dental services, to process payments, to collect unpaid accounts, or to refer uncollected fees to the designated collection department and credit bureau.
    • To process claims for payments or reimbursement from third party health benefit providers.
    • We require a 24hr notice for cancellation and reserve the right to charge a fee for appointments missed with no notice.
    • To send patient information material about our dental practice.
    • To disclose to other healthcare professionals such as physicians if the patient with their consent, has been referred by us to the other healthcare professionals for either second opinion or treatment.
  • Should be Empty: