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New Patient Forms
Home
Services
Our Team
Our Practice
Contact
New Patient Forms
Calgary Family Dental Clinic for all your Dentistry Needs
New Patient Form
New Patient Form
New Patient Form
Patient Information
Title
Mrs.
Ms.
Mr.
Dr.
Name
*
First Name
Last Name
Marital Status
Married
Widowed
Separated
Divorced
Single
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (Primary)
*
(###)
###
####
Phone (Secondary)
(###)
###
####
Email
Date of Birth
*
MM
DD
YYYY
Gender
Female
Male
Other
Alberta Health Care#
Emergency Contact
Emergency Phone Number
(###)
###
####
Insurance Information
Primary Insurance Company
Policy Holder Name
Insured Birthday
MM
DD
YYYY
Group/Policy/Plan #
I.D./Certificate #
Relationship to Patient
Additional Insurance Provider (Leave Blank if Not Applicable)
Secondary Insurance Company
Policy Holder Name
Insured Birthday
MM
DD
YYYY
Group/Policy/Plan #
I.D./Certificate
Relationship to Patient
Referral
How did you hear about us?
Friend Referred
Location (Walk-in)
Website/Google
Yellow Pages
Local Advertising
Social Media
Other
Referral Name
Consent for Services
*
I understand that I am personally responsible for payment of all dental services rendered. Our practice will on your behalf help prepare patients insurance forms or assist in making collections from the insurance company and will credit any such collections to your account. Dental insurance plays a role in helping patients to acquire dental care however it cannot interfere with the proper diagnosis and treatment recommendations. Treatment recommendations are made on your dental health needs not on what insurance coverage you may or may not have. I understand that the fees estimated for dental care can only be extended for a period of 3 months from the date of the patient exam. The undersigned affirm that the information given in this questionnaire is true and accurate to the best of their knowledge.
I authorize the dental staff to perform such dental services as may be necessary and authorize the release of written records to any referring or treating dentist, physician, medical facility or insurance company for legal documentation.
Confidential Medical Information
Do you currently experience, or have you ever had any of the following? Please check/circle all that apply:
Angina
Arthritis/Rheumatism
Asthma
Blood Thinners
Bruise Easily
Blood Disorder/Anemia
Hepatitis A/B/C
Hyper/Hypo Glycemia
Bone/Muscular/Joint Disorders
Diabetes
Sinus Problems
Stomach Problems/Ulcers
Swelling of Ankles
Snoring or Trouble Sleeping
Drug/Alcohol Dependency
Do you use cannabis
Do you Smoke
Epilepsy/Seizures
Fainting
Frequent Headaches
Claucoma
Heart Disease
Heart Murmur
Stroke
Troubles Breathing
Cortisone/Steroid Therapy
Tuberculosis
Cold Sores
Organ Transplants or Medical Implants
Other Conditions
HIV Infections/AIDS
Sexually Transmitted Disease
Head/Jaw/Face Injuries
High Blood Pressure
Low Blood Pressure
Joint Replacements
Kidney Problems
Liver Disease
Lung Disease/Emphysema
Thyroid Disorder
Cancer/Chemotherapy
Cancer/Radiation
Mental/Nervous Disorder
Osteoporosis
Rheumatic/Scarlet Fever
Shortness of breath/chest pain
Please elaborate on any of the above:
Have you ever had a serious illness or condition requiring medical care? If yes, please specify:
Do you take any prescription or non-prescription drugs regularly? If yes, which ones?
Do you take BLOOD THINNERS?
Yes
No
Please specify:
Have you ever experienced unusual reaction to any of the following?
Penicillin
Local Anesthetic
Aspirin
Codeine
Sulpha Drugs
Latex
Other
Please Explain:
Do you have any minor or serious allergies? If so, which ones?
Women Only: Are you currently pregnant or suspect you might be?
Yes
No
If so, how many weeks?
Previous Dental History
Former Dentist
Last Visit Date
Do you have a specific concern you would like addressed? If yes, please describe:
How often do you brush your teeth?
How often do you floss your teeth?
Are your teeth sensitive to:
Hot
Cold
Sweets
Biting
Chewing
Do you gums bleed easily?
*
Yes
No
Are you aware of an unpleasant taste in your mouth or bad breath?
*
Yes
No
Do you experience any tightness, clicking or pain in the jaw joint?
*
Yes
No
Do you clench or grind your teeth?
*
Yes
No
Do you bite your nails or suck your thumbs or fingers?
*
Yes
No
What cosmetic changes would you make to your teeth?
Straighten
Whiten
Improve Shape
Other
Please specify any any of the above:
If you recently had surgery or will be having surgery, do you require pre-medication for dental treatment? Please specify type of surgery
On a scale of 1 to 5 how nervous do you feel coming to the dentist?
1 = Not nervous at all 5 = Very nervous
1
2
3
4
5
Consent for Services
*
I certify that I have provided an accurate and complete personal and medical/dental history to Le Family Dental and have no knowingly misled or omitted any information. I have had the opportunity to ask questions and fully understand all the questions on this form. I authorize the dentist to perform diagnostic procedures and treatment as necessary for proper dental care. I understand consultation with my medical doctor may be required and I consent to my physician being contacted if necessary. I authorize the free exchange of information between Le Family Dental and my dental insurance agency including contact information, coverage, treatment planned and completed.
Patient Agreement
Consent for Services
I hereby certify that this medical and dental history is accurate and complete to the best of my knowledge.
I consent to the performing of the dental procedures agreed to be necessary or advisable, including the use of local anesthetic or any drugs as indicated.
I consent to the collection, use and disclosure of my, my child's, and families personal information.
I am aware of the risks involved in any medical procedure and this office will not be held accountable for adverse effects that may occur.
I have been informed and understand that the practice of dentistry is not an exact science: no guarantees or assurance as to the outcome of prosthetic treatment or surgery can be made due to the uniqueness of every individual clinical situation. In most instances, the outcome of the treatment is most satisfactory.
I understand that failure to keep financial arrangements up to date will result in account closure and my file being sent to collections.
Our office will be charging a $100.00 fee for any missed appointments or cancellations given under 24 hours (business days) notice.
I give consent to Le Family Dental to contact me through email if necessary.
Important*
As a service to our patients we want to continue to bill your insurance company. However, please understand that the insurance coverage is a contract between the patient, the insurance company and the employer, not the dentist. The benefits you receive are based on the terms of the contract that were negotiated between your employer and the dental insurance company and not your dental centre.
Name of Insured
First Name
Last Name
Patient
Parent
Guardian
Relationship to Patient
Digital Scan
*
Do you consent to digital scanning and photographs of your teeth for diagnosis and educational purposes?
Yes
No
Thank you for filling out the new patient forms!
Le Family Dental will be in touch with you soon!