New Patient Form - Dentist Calgary | Serving SW Calgary AB

New Patient Intake Form

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- Step 1 of 3

Patient Name *

First

Middle

Last

Patient's Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient's Date of Birth

Patient Phone *

If you need an appointment for someone under 18, please provide your own contact details.

Patient Email Address *

Confirm Email

If you need an appointment for someone under 18, please provide your own contact details.

medication, and antibiotics

Patient's gender *

Personal responsible for account *

Who's responsible for the account?

Do you have dental benefits?

Insurance Company Name

Group Policy Number

Preferred Appointment Times *

Any
Morning
Afternoon
Evening

Preferred Appointment Day *

Monday
Tuesday
Wednesday
Thursday
Friday

Employer Name

Occupation

Previous Dentist

Family Physician

In case of emergency please notify: *

Relationship

Phone Number

How did you hear about us? *

Please tell us how you heard about us.

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. Please fill in the entire section.

Are you in good health? *

Has there been any change in your general health in the past year? *

If no, please explain:

If yes, please explain:

Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind? *

Do you have any allergies? (e.g. penicillin, latex/rubber product) *

If yes, please list all medications, non-prescription drugs, herbal supplements you are taking: *

If yes, please list all allergies: *

What pharmacy do you use for your medications?

Do you bleed or bruise easily? *

Pharmacy Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have a heart problem of any kind? *

Have you ever had a peculiar or adverse reaction to any medicines or injections? *

If yes, please explain:

Have you ever been exposed to Hepatitis or Jaundice? *

Have you ever had a heart murmur, mitral valve prolapse or rheumatic fever? *

Have you ever been hospitalized for any illness or operations? *

Have you ever been advised by your doctor to take antibiotics before dental treatment? *

If yes, please explain:

Are you pregnant or breast-feeding? *

Do you have or have you ever had any of the following?

AIDS
Anemia
Arthritis/Rheumatism
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive bleeding
Fainiting
Hay fever
Head injuries
High/Low blood pressure
Hip replacement surgery
Knee replacement
Kidney disease
Lung disease
Mental disorder
Prosthetic heart valve
Stomach ulcer
Stroke
Thyroid problem
Tuberculosis
Venereal disease
Osteoporosis
Artificial joint (knee/hip)

Please check those that apply.

Are you currently taking bisphosphonate medication? *

Have you ever had any illness not included above? *

If yes, please specify:

Have you ever had a dental examination with a full series of x-rays of your teeth and jaws? *

When was your last dental visit? *

Have you ever had any complications/reactions with past dental treatments? *

Have you ever had any problems/reactions to local anaesthetic? *

If yes, please explain:

Do your gums bleed when:

Brushing
Flossing
Spontaneously

Are your teeth sensitive to:

Cold
Sweets
Heat
Other

Does food lodge between your teeth? *

If other, please explain:

Do you grind or clench your teeth? *

Do your gums feel swollen or tender? *

Reason for today's clinic visit? *

Does your jaw crack, pop, or grate when opened widely? *

If other, please explain:

Office Policy Agreement (Required Reading) *

I have read, understand, and agree to London Heritage Dental's office policies outlined below.

We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient's responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to be paid for at each visit as they are performed.

Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointment without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient's responsibility.

I authorize London Heritage Dental to perform all dental or diagnostic procedures agreed to be necessary or advisable, including x-rays, photographs, and the use of local anaesthetic or other medications as indicated. I understand that if I miss an appointment or provide less than 48 hours notice to cancel or reschedule an appointment, I may be charged a cancellation fee. I assume full responsibility for fees associated with my dental treatment and those of my dependents. I have read and fully understand the above conditions of treatment and I accept my responsibility as a patient at this office.

Signature of patient, parent, or guardian *

Clear Signature