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New Patient Medical Form

 We collect and use your health information under the Health Information Act (HIA) section 20; only to support the health services we provide to you. We will not disclose your health information to non-healthcare agencies without your consent or as required by law. If you have questions about the collection and use of any information on this form, contact the Clinic Privacy Officer at (403) 457-8400 or by email: 

New Patient Medical Form

Westside Endodontics

Patient Information:

Select one

Referring Dentist Information:

Emergency Contact Information:

Medical Information:

The following information is required so that we may provide you with the best possible care. The doctor will review all of the questions. Please fill out the entire form. If you need further clarification of any of the questions, please ask a team member or the doctor.

1. Are you currently being treated for any medical condition now or within the past year?
3. Do you have or have you ever had any of the following conditions?
5. Do you have any allergies that result in rash, hives or swelling (ie; to medications, latex products, etc.)?
6. Have you ever had an adverse reaction (nausea, dizziness) to any medications or injections?
7. Do you have or have you ever had asthma?
Did you bring your inhaler with you today?
8. Do you have an artificial or prosthetic joint/heart valve?
9. Do you have any conditions or have you had any therapy that could affect your immune system?
If yes, is it?
10. Have you ever had hepatitis, jaundice or liver disease?
11. Do you have a bleeding problem/disorder?
12. Have you ever been hospitalized for any illness or operations?
13. Do you smoke or chew tobacco products?
14. Are you anxious/nervous during dental treatment?
Have you been prescribed medication in thepast to help you relax during dental appointments?
15. For Women: Are you pregnant or breast-feeding?
16. Are there any other conditions not listed that you have had?

Dental Insurance Information:

Credit Card Payment

Please note that the complete cost of the dental visit will be due on the date of service by Visa, MasterCard, or Debit. We do not accept personal cheques or cash. We can assist you by sending your insurance forms to your insurance company on your behalf. Your insurance company will reimburse you directly for the coverage you have with them.

Thank you for sending your form to us at Westside. Your form has been submitted!

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