Adult Patients | Millennium Dental | SE Calgary Dentist Douglas Glen

PERSONAL INFORMATION

Name:*

Today's Date:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone home:

work:

Cell:

Date Of Birth:

Sex:

M
F

Email Address:*

Employer:

occupation:

Emergency Contact:

Phone:*

Physician:

Phone:

Previous Dentist:

Phone:

How did you here about our clinic?

Medical History

When did you last see your physician, and for what reason

Do you have any drug allergies that you are aware of?

Yes
No

Please List:

Do you have a latex allergy?

yes
No

Have you ever been hospitalized?

Yes
No

For what reason

Did a dentist,physician or specialist ever recommend taking antibiotics prior to dental treatment or surgery?

Yes
No

Please List any mediciations & supplements you are taking:

Please check any of the following conditions that apply to you, past or present

women

Are you pregnant?

Yes
No

Birth control pills or HRT?

Yes
No

Are you in peri-menopause or menopause?

Yes
No

Tobacco

Were you/are you a smoker?

Yes
No

For how long?

how much?

Past/future Quit Date:

Do you chew tobacco?

Yes
No

Is there anything else you would like us to know about your health?

Appointment policy:

We would like to ask for a minimum of 2 BUSINESS DAYS NOTICE If for any reason you will be unable to keep a scheduled appointment. This consideration will allow us to accommodate those patients that may be waiting for an appointment. For your convenience, we will continue to call or email you prior to your appointment to remind you and receive conformation for your visit

I*

have read & understand the above policy, Date*

Signature:

Dental History

What is your present dental concern?

Are any of your teeth sensitive or aching?

Yes
No

Which tooth area?

When was your last dental visit?

Last professional cleaning?

Have you ever had any bad or good experiences at a dental office you would like to make us aware of?

Yes
No

What is your dental comfort level from 1 to 10?

1= not comfortable; 10= completely comfortable

How often do you brush your teeth?

Floss?

Do you use (Pleose check):

Mouthwash
Toothpicks
Proxy-brush
Floss Threaders

Others (Please list):

Have you noticed any bad breath, mouth odors or a bad taste in your mouth?

Yes
No

Does you mouth often seem dry?

Yes
No

Do you notice bleeding when you brush?

Yes
No

Floss?

Yes
No

are you ever been diagnosed with: (Pleastarcle):

Gingivitis
Gum Disease
Periodontal Disease
Deep Pockets

Any other condition related to the health of your gums?

Yes
No

Please list

Rate your SMILE from 1 to 10?

1=disllke my smlle 10=love my smile

What would you like to change or improve in your smile or your mouth in general

The following list of the symtoms can be signs of TMJ/TMD or bite problems, Please check any that may apply to you

The following list of the symtoms can be signs of SLEEP OR BREATHING Disorder, Please check any that may apply to you

Is there anything else you would like to make us aware of that has not been covered on this form?

Yes
No

Please List

PERMISSION TO TREAT/RELEASE OF INFORMATION/PRIVACY

This is to certified that I, The Undersigned,consent to that performance of dental treatment agreed to be necessary of advisable by the dentist. I will assume full responsibility for fees associated with treatment. I authorized release;to my dental benefits and the CDA, information contained i claim submitted electronically. I also authorized the communication of information related to the coverage of services described to the named dentist. The authorization shall continue in effect until the undersigned revoke the same . I am aware the office has a privacy policy which i can view at any time

Date:*

Signeture of patient/parent/guardian:*

Dental Insurance

We are more than happy to help you with your insurance claims. Payment in full is required at the time of service , whnever possible , we will electronicaly send your insurance claim, which will speed up the process for yoiu and you should recieve your insurance, reembrancement within few short day.

primary policy

Employer:

Provider:

Group #

I.D #

Secondary policy

Employer:

Provider:

Group #

I.D #

If insurance belongs to your spouse please add name:

Birthday:

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Comprehensive Aesthetic Dentistry

New Patient Form for adults

PERSONAL INFORMATION

Medical History

women

Tobacco

Appointment policy:

Dental History

PERMISSION TO TREAT/RELEASE OF INFORMATION/PRIVACY

Dental Insurance

primary policy

Secondary policy