Confidential Information Questionnaire








Date of birth
Person we can contact in case of an emergency :


Insurance Information

Date of birth


Date Of Birth


I understand that all of the information that I have provided today is correct to the best of my knowledge. I understand it will be held in strict confidence and only be used to improve communication between this office, myself and other dental specialists if required. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time service are rendered and authorize my dental office to submit my claims electronically on my behalf

Patient medical history

Are you in good health?
YN

Have there been any changes in your general health within the past year?
YN

Date of your last physical exam

Are you now under the care of a physician?
YN

Have you ever been hospitalized for any surgical operation or serious illness
YN

Are you taking any medicines including non-prescription medicines? If yes. What are you taking?

Bruise easily or abnormal bleeding?
YN

Have you ever required a blood transfusion?
YN

Have you had recent weight loss?
YN

Have you ever taken Fen-Fen or Redux?
YN

Have you ever had bisphosphonate drugs for Cancer or Osteoporosis?
YN

Do you use tobacco
YN

Do you or have you used controlled drugs?
YN

Are you wearing contact lenses?
YN

Do you have any disease, condition or problem not listed above that you think we should know about?
YN

Women:

Are you pregnant?
YN

Are you nursing?
YN

Taking birth control?
YN

Are you allergic to or have you had serious reactions (other than stomach upset) to:

Penicillin or other antibiotics
YN

Sulfa drugs
YN

Barbituates, Sedatives or sleeping pills
YN

Aspirin or similar NSAIDs
YN

Iodine or shellfish
YN

Any metals
YN

Latex/rubber
YN

Other (please list)
Do you or have you had the following:

Rheumatic heart disease or Rheumatic fever
YN

Scarlet fever
YN

Heart defect/murmur, Mitral valve prolapse
YN

Heart surgery, trouble, attack or angina
YN

Chest pain, shortness of breath, pacemaker
YN

High/Low blood pressure, hepatitis, jaundice or liver disease
YN

Have you ever had any of the following:?

Stroke
YN

Sinus trouble
YN

Lung or breathing problems
YN

Asthma or hay fever
YN

Hives or skin rash
YN

Fainting or dizzy spells
YN

Diabetes
YN

AIDS or HIV infection
YN

Thyroid problems
YN

Allergies
YN

Arthritis, rheumatism, fibromyalgia
YN

Joint replacement or any implant
YN

Stomach ulcer, reflux, IBS, Crohn’s
YN

Kidney trouble
YN

Tuberculosis, persistent or bloody cough
YN

Chemotherapy for cancer or leukemia
YN

Sexually transmitted disease
YN

Epilepsy or seizures, MLS Y
YN

Anemia or blood disorders
YN

Glaucoma
YN

Nervousness or phobias
YN

Tumors or Cancer
YN

Mental healthcare
YN

Back problems
YN

Chemical dependency, addictions
YN

Cortisone treatment
YN

Cold sores/fever treatment
YN

Hypoglycemia
YN

Eating disorders, bulimia, anorexia
YN

Chronic pain condition
YN

Head or neck trauma, whiplash
YN

Hypochondriasis
YN

Other (please list)

Patient Dental History

Reason for visit today?
Date of last dental visit?
Other (please list)
Previous dental office(Name/location)
Date of last x-rays

Mark all that you are concerned about/currently have:

West Airdrie Dental financial agreement

Please Choose option 1 or option 2

Option 1

If you are unable to leave a valid credit card on file, all accounts are paid by you, at time of service and the insurance claim is sent off electronically by our office at the time of your appointment. The insurance cheque is mailed directly to you.

Option 2

West Airdrie Dental will accept direct payment from your insurance, leaving you to pay the difference that the insurance does not cover. For this we accept DEBIT, VISA or MASTERCARD only.
In choosing this option we require a valid credit card on file.
I authorize West Airdrie Dental to put through any outstanding balance automatically on my credit card.

Exp:
Date:
IMPORTANT: Due to recent legislation, you are covered under the privacy act; your information through your insurance provider is confidential and will not be released to our office. Therefore, we urge you to become familiar with any dental benefits you have. The office will not predetermine your basic dentistry, should you request this we would be more than happy to do this for you on your behalf. If you or your insurance company requires pre authorization for any treatment, we will be happy to provide you with the information. Ultimately if there is a problem with your insurance it is your responsibility.

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