4910 Roper Rd NW, Edmonton, AB T6B 3T7, Canada
(780) 465-0994 Book Appointment

New Patient

    Person responsible for account: selfspouseother
    Name:
    Patient Name:
    D.O.B
    Alberta Health Care Number:
    Preferred Ph #:
    Alternative Ph#:
    Address:
    Email:
    Employer:
    Phone #:
    How did you hear about our office?
    PRIMARY DENTAL INSURANCE:
    Subscribers name:
    D.O.B:
    Relationship: selfspouseChildother
    Ins. Co Name:
    Group/Policy #:
    Certificate/ID #:
    Dental Coverage: Basic (%)
    Dental Ortho: (%)
    Major (%)
    Benefit year:
    Yearly Maximum: ($)
    SECONDARY DENTAL INSURANCE:
    Subscribers name:
    D.O.B:
    Relationship: selfspousechildother
    Ins. Co Name:
    Group/Policy #:
    Certificate/ID #:
    Dental Coverage: Basic (%)
    Dental Ortho: (%)
    Major (%)
    Benefit year:
    Yearly Maximum: ($)
    MEDICAL HISTORY
    Please Yes or No to each question. If unsure of a question, please consult with us.
    Are you being treated for any medical condition at present or within the last two years? YesNo
    Have you been hospitalized in the last two years? YesNo
    Are you presently taking any PRESCRIPTION or NON-PRESCRIPTION drugs, supplements, or herbs? YesNo
    Have you ever reacted adversely to any of the following? YesNo
    Have you been advised by your Medical Doctor or Dentist to take antibiotics prior to treatment? YesNo
    Have you ever had any injury or surgery to your face or jaws? YesNo
    Do you smoke, chew, or use any form of tobacco? YesNo
    Do you smoke, vaporize, or use any form of cannabis? YesNo
    Do you vaporize e-juice? YesNo
    Are you alcohol or drug dependent? YesNo
    WOMEN ONLY: Are you pregnant or suspect you may be? YesNo

    PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS (PAST OR PRESENT) YOU MAY HAVE:

    Anemia
    Food allergy
    Hodgkin’s disease
    pneumonia
    Angina
    Glandular disorders
    Hypo / Hyperglycemia
    Prostate problems
    Arthritis/rheumatism
    Glaucoma
    Jaundice
    Radiation / Chemotherapye
    Artificial joint: Hip/knee
    Hay fever
    Kidney disease
    Rheumatic / Scarlet fever
    Asthma
    Hearing impaired
    Last blood pressure
    Sickle cell disease
    Abnormal bleeding
    Heart attack
    Sinus trouble
    Bronchitis
    Heart disease
    Latex allergy
    Sleep Apnea
    Cancer
    Heart murmur or defect
    Liver disease
    Stomach / digestive issues
    Circulation issues
    Heart pacemaker
    Low blood pressure
    Stroke
    Congenital heart lesions
    Heart rhythm disorder
    Lung disease
    Swelling of limbs
    COPD / Emphysema
    Heart surgery
    Metal allergy
    Thyroid disease
    Cortisone / steroids
    Hepatitis A / B / C
    Mental health condition
    Tuberculosis
    Crohn’s Disease
    Herpes (cold sores)
    Migraines
    Ulcers
    Diabetes: Type I or II
    High blood pressure
    Mitral valve prolapse
    Visually impaired
    Epilepsy or seizures
    HIV / AIDS
    Neurologic condition
    Fainting / dizzy spells
    Hives / skin rashes
    Organ transplant
    other:
    Is there anything else about your health we should be aware of?
    DENTAL HISTORY

    Please Yes or No to each question. If unsure of a question, please consult with us.

    Is there a dental problem or concern you would like treated immediately? YesNo
    Have you been seeing a dentist regularly? YesNo
    Are there any growths or sore spots in your mouth? YesNo
    Do your gums bleed when brushing or eating? YesNo
    Do you suffer from pain or swelling of your gums? YesNo
    Have you noticed any loose teeth, or have any of your teeth shifted? YesNo
    Are any of your teeth sensitive to: YesNo
    Do you experience dental anxiety? YesNo

    Please indicate if you have any of the following dental treatments in the past:

    Periodontal Treatment
    Crown(s) or Bridge(s)
    Orthodontic Treatment
    Dental Implant(s)
    Dentures or Partial Dentures
    Root Canal Treatment
    Wisdom Teeth Removal
    Night Guard, Bite plate or appliance

    Please indicate if you experience any of the following in relation to your jaw joint:

    Popping / Clicking
    Difficulty opening or closing
    Pain in your jaw joints, ear or side of face
    Stiff or sore shoulders, neck or back
    Ringing / Congestion in the ears
    Pain where your teeth are clenched
    Pain or difficulty while chewing
    Clenching or grinding your teeth
    Headaches (especially upon wakening)
    Trouble swallowing

    Please indicate if you experience any of the following in relation to your jaw joint:

    Biting your cheeks or lips
    Sleep problems, restless sleep, snoring
    Mouth breathing while awake or asleep
    Gag reflex
    Yes
    No
    I, certify that all the Medical and Dental information is true to my knowledge and I have not omitted any pertinent information.
    TREATMENT CONSENT:
    This is to certify that I, , consent to the performing of the diagnostic, dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated. I fully understand the office policy and I will assume responsibility for fees associated with those procedures performed.
    PERSONAL INFORMATION & CONFIDENTIALITY CONSENT:

    I consent to the collection, use, retention and disclosure of personal information as is required for myown and my dependents dental care.

    Signature (patient or guardian)
    DATE