New Patient Form Adult

Name of Person on the original form *

First Name Last Name

Name of Patient *

First Name Last Name

Birth Date *

Date Format: MM slash DD slash YYYY

Marital Status*

Select a Choice *

Male
Female

Work Phone

Cell Phone

Email *

Employer *

Spouses Name *

Person to Contact in Case of Emergency *

University/College Student *

Full Time
Part Time
N/A

How would you prefer your appointment reminders? *

Via Mail
Phone Call
Text Message

Relationship to Patient *

Phone Number *

Do you have insurance? *

YES
NO

Do you have secondary insurance? *

YES
NO

Are you dissatisfied with the appearance of your smile? *

YES
NO

Do you have? (please check the following that apply)

Chipped Teeth
Protruding Teeth
Crowded Teeth
Misshapen Teeth
Teeth with Spaces or have gaps
Teeth with old fillings or dental work
None

If you could change one thing about your smile, what would it be?

What is your primary reason for booking the appointment is today? *

Have you had a negative experience, or is there something you would like us to know that will help us make your visit more comfortable? *

Address *

Street Address City State / Province / Region ZIP / Postal Code Country

INS Information

0 of 500 max characters

List Medications

0 of 500 max characters

Patient Medical History

Physician *

Physician's Office Phone *

Are you currently under any medical treatment? *

YES
NO

Have you been admitted to a hospital or needed emergency care during the past two years? *

YES
NO

Are you currently taking any medications, including over the counter medications? *

YES
NO

Have you ever had any complications following dental treatment? *

YES
NO

Are you pregnant? *

YES
NO

Do you have any allergies to medications? *

YES
NO

Do you have or have had any of the following? Please check all that apply. *

AIDS/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizzieness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Mental Disorders
Pacemaker
Radiation Therapy
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Strock
Tuberculosis
Tumors
Venereal Disease
Smoker
None

Patient Dental History

Check All That Apply *

Gums bleed while you brush
Your teeth are sensitive to hot or cold liquid/foods
You feel pain in any of your teeth
Have any sores/lumps in your mouth
Have any head, neck or jaw injuries
Ever experience any clicking or pain in the TMJ area, difficulty opening or closing
Have frequent headaches
You clench or grind your teeth
You bite your lips or cheeks frequently
Had any difficult extractions or prolonged bleeding from it in the past
Had any orthodontic treatments
You wear dentures or partials
None

Upload a Photo

We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.

I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that West Airdrie Dental can electronically file dental claims on my behalf.

In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.*

*

I have read the above conditions of treatment and payment and agree to their content.

New Patient Form Additional Adult

Patient Medical History

Patient Dental History

Upload a Photo