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: info@wsendodontics.com

New Patient Medical Form

Patient Information:

Full Name

Date of Birth

Phone Number

Street Address

Town/City

Select one

Mr.

Mrs.

Ms.

Dr.

Alt. Phone Number

Province/Territory

Postal Code

Referring Dentist Information:

Referring Dentist Name

Dentist Phone Number

Emergency Contact Information:

Emergency Contact Name

Emergency Contact Phone Number

Relationship

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?

Yes

Not Sure

If yes, please briefly explain the condition

2. Describe any current medical treatment, upcoming surgery or upcoming treatment that may affect your dental treatment.

Please briefly explain:

4. List any medications, supplements or vitamins taken within the last 2 years. (Drug & Purpose)

5. Do you have any allergies that result in rash, hives or swelling (ie; to medications, latex products, etc.)?

Yes

Not Sure

If yes, explain what is the allergy and what caused the following reaction(s)

6. Have you ever had an adverse reaction (nausea, dizziness) to any medications or injections?

Yes

Not Sure

If yes, please expain.

7. Do you have or have you ever had asthma?

Yes

If yes, do you use an inhaler & if so what kind?

Did you bring your inhaler with you today?

Yes

8. Do you have an artificial or prosthetic joint/heart valve?

Yes

9. Do you have any conditions or have you had any therapy that could affect your immune system?

Yes

If yes, please explain.

10. Have you ever had hepatitis, jaundice or liver disease?

Yes

11. Do you have a bleeding problem/disorder?

Yes

12. Have you ever been hospitalized for any illness or operations?

Yes

If yes, please explain.

13. Do you smoke or chew tobacco products?

Yes

14. Are you anxious/nervous during dental treatment?

Yes

Have you been prescribed medication in thepast to help you relax during dental appointments?

Yes

If yes, which medication?

15. For Women: Are you pregnant or breast-feeding?

Yes, I am pregnant

Yes, I am breastfeeding

If yes to pregnancy, how many months?

16. Are there any other conditions not listed that you have had?

Yes

If yes, please explain.

I confirm that the above information is correct, to the best of my knowledge. Further, I consent to the collection, use or disclosure of my or my dependents (“the patient”) personal information as it is required for my own and/or dependents dental care. I also consent to receiving emails regarding my treatment.

Patient/Parent/Guardian Signature

Date:

Dental Insurance Information:

Primary Insurer:

Primary Subscriber Name:

Group/Plan #

ID #

Date of Birth

Secondary Insurer:

Secondary Subscriber Name:

Group/Plan #

ID #

Date of Birth

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.

I understand that I am fully responsible for the prompt and full payment of my account. I also authorize the release of financial information to my dental plan benefits plan administrator and the Canadian Dental Association in order to facilitate the submission of my electronic dental claims submission by this office on my behalf.

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