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DENTAL CLINIC
Family Dentist
Sleep Apnea
Emergency Dentist
Sedation for Anxiety
Children’s Dentist
Wisdom Teeth Removal
Sports Mouthguards
Teeth Grinding
TMJ
Dental Cleanings
Senior Dental Care
Cosmetic Dentistry
What’s Right For Me?
Teeth Whitening
Invisalign
Veneers
Dental Implants
Implant Dentures in Calgary
Botox
Sleep Apnea
For Patients
Pricing
Canada Dental Benefit Program
Best Dentist Calgary
Direct Insurance Billing
Our Patient Experience
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Dentist in Fairview
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Dentist Calgary SE
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New Patients Form
Please complete this detail form prior to your first appointment with us at Macleod Trail Dental!
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
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Country
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Panama
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Virgin Islands, U.S.
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Email
*
Are you a current patient?
*
Yes
No
Phone
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Gender Pronouns
Occupation
Hobbies
Spouse's (Significant Other's) Name
Spouse First Name
Spouse Last Name
Date of Birth Spouse
MM slash DD slash YYYY
In case of emergency, contact (close relative)
How did you find us
Family members that are patients
Primary Insurance Information
Full Name of Insured
Date of Birth
MM slash DD slash YYYY
Name of Insurance Company
ID / Certificate number
Policy number
Name of employer
Secondary Insurance Information
Full Name of Insured
Birthday
MM slash DD slash YYYY
Name of Insurance Company
ID / Certificate number
Policy number
Name of employer
General Health
*
Good
Fair
Poor
Last Physical
*
This Year
Last Year
Longer Ago
Current Physician
Current Physician's Address
Current Physician's Phone Number
Previous Dentist
Previous Dentist's City
Last Dental Exam
*
This Year
Last Year
Longer Ago
Last Dental X-rays
*
This Year
Last Year
Longer Ago
Last Dental Cleaning
*
This Year
Last Year
Longer Ago
Do you smoke
*
Yes
No
If so, how much :
Do you have any allergies
*
Yes
No
Please list all allergies
Do you require any medications prior to dental treatment
Yes
No
If so, what medications :
Please list all medications you take on a regular basis
Anemia
*
Yes
No
Angina Pectoris
*
Yes
No
Arthritis/rheumatism
*
Yes
No
Blood disorder
*
Yes
No
Bronchitis
*
Yes
No
Cancer
*
Yes
No
Circulation Problems
*
Yes
No
Congenital Heart issues
*
Yes
No
Cortisone/steroids
*
Yes
No
Diabetes
*
Yes
No
Emphysema
*
Yes
No
Fainting or dizzy spells
*
Yes
No
Glandular disorders
*
Yes
No
Glaucoma
*
Yes
No
Head/Neck injuries
*
Yes
No
Heart disease or attack
*
Yes
No
Heart murmur
*
Yes
No
Heart pacemaker
*
Yes
No
Heart rhythm disorder
*
Yes
No
Hepatitis A
*
Yes
No
Hepatitis B
*
Yes
no
Hepatitis C
*
Yes
No
HIV
*
Yes
No
High/low blood pressure
*
Yes
No
Hodgkins disease
*
Yes
No
Hyper-(hypo) Glycemia
*
Yes
No
Hypertension
*
Yes
No
Jaundice
*
Yes
No
Joint replacement
*
Yes
No
Kidney disease
*
Yes
No
Latex allergy
*
Yes
No
Liver disease
*
Yes
No
Lung disease
*
Yes
No
Major accidents
*
Yes
No
Malignant Hyperthermia
*
Yes
No
Metal allergy
*
Yes
No
Mitral valve prolapse
*
Yes
No
Organ transplant
*
Yes
No
Medical implant
*
Yes
No
Psychiatric care
*
Yes
No
Radiation treatment
*
Yes
No
Chemo-therapy
*
Yes
No
Rheumatic/Scarlet fever
*
Yes
No
Sickle cell disease
*
Yes
No
Sinus trouble
*
Yes
No
Stomach/Intestinal issues
*
Yes
No
Stroke
*
Yes
No
Thyroid disease
*
Yes
No
Tuberculosis
*
Yes
No
Ulcers
*
Yes
No
Pregnant and/or nursing
*
Yes
No
Birth Control Medication
*
Yes
No
Botox
*
Yes
No
Recreational drugs
*
Yes
No
Do you drink grapefruit juice
*
Yes
No
Drug/alcohol dependency
*
Yes
No
Multiple sclerosis
*
Yes
No
Anxiety/depression
*
Yes
No
Asthma
*
Yes
No
Epilepsy/seizures
*
Yes
No
Headaches
*
Yes
No
Eating disorder
*
Yes
No
Neurological disorder
*
Yes
No
Artificial heart valve
*
Yes
No
DENTAL HISTORY QUESTIONNAIRE
The following information is required to enable us to fully evaluate your dental history and provide complete options for your future care based on both your dental requirements and your satisfaction with your teeth
When was your last dental hygiene appointment :
Are you experiencing any discomfort at this time
*
Yes
No
Do you currently experiencing any of the following
*
Loose Teeth
Bleeding Gums
Sensitive Teeth
Missing Teeth
Swelling in Mouth
Food packing between teeth
unsatisfactory Dentures
Bad Breath
Sore Gums
Floss shredding between teeth
Bad Breath
Oral Ulcers
Unsatisfactory Crown or Bridges
None of the above
Have you ever had any of the following
*
Root Canals
Grinding appliance Therapy
Implants
Bite Adjustment
Oral Cancer
Crowns/Bridges
Periodontal Therapy
Orthodontics
Oral Surgery
Floss shredding between teeth
Bad Breath
Oral Ulcers
Splint / Nightguard
None of the above
Are you happy with the appearance of your teeth
*
Yes
No
What would you like to change or discuss with us
*
Color
Length
Silver Fillings
Crowding
Spacing
Too much Gum showing
Overbite
Shape
White / dark spots on your teeth
Other
As part of your examination we will also analyze the condition of your bite, jaw joints, and muscles of the head and neck. Many people experience symptoms they feel are "normal" or may be caused by other things as allergies or stress. Many of these symptoms may be related to your bite. We would like you to answer these questions as honestly as possible even if you do not feel they are in direct correlation to your bite. Do you suffer any of the following:
*
Recurrent headaches
Migraines
Jaw Locking
Pain with Chewing
Clenching of Teeth
Numbness in Hands / Arm
Jaw Stiffness
Insomnia/snoring
Grinding of Teeth/ Tired jaw in morning
Ear Ache
Ringing / Buzzing in Ears
Dizziness
Jaw Joint Noise
Difficult Swallowing
Tired Eyes / Red Eyes
Pain behind Eyes
Neck Pain
Shoulder Pain
Back Pain
Tingling
Facial Numbness
Congested Ears
None of the above
Do you see a Chiropractor, massage therapist, or a physiotherapist
*
Yes
No
Have you ever had any major accidents
*
Yes
No
Is time a factor in your decision regarding your dental treatment
*
Yes
No
On a scale of 1 to 10, how important is the health of your teeth and gums
At what point do you usually initiate dental treatment
*
Tooth hurts or breaks
Something is not ideal
Something is worsening
Other
What type of dentistry do you want us to recommend
*
Just patch it
Short Term
Long Term
We have the unique ability to look at your mouth from three Perspectives. Which of these would you like us to use for you: (Please check all that apply)
*
General Dentist
Cosmetic Dentist
Functional Dentist
How did you hear about us :
*
Family / Friends
Website
Other
Please let us know if there is anything that you would like us to know about your previous dental history that would assist us in providing you with the best Individualized Treatment that we have available :
REMINDER:Please don't forget! You also have to fill out the 'Personal Information Form.
Personal Information & Financial Consent Policy
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell telephone numbers, and email addresses. (Collectively referred to as “Contact Information”) Contact Information is collected and used for the follow purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To send reminders to patients concerning the need for further dental examination or treatment To send patients informational material about our dental practice Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf. Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients Medical Information is disclosed: -To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment or all or part of the cost of dental treatment or has asked us to submit a claim on their behalf -To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion -To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment -To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion -To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or a treatment If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest. I authorize Macleod Trail Dental/South Centre Dental to communicate on behalf of myself and all dependents named on my insurance plan, with my insurance company and/or plan administrator with which I may at any time have coverage. I authorize release of personal/financial/dental/medical Information to the same.
Appointment Policy
We do require 48 hours’ notice to change or cancel an appointment. It is our policy to personally confirm your appointment prior to the appointment date. Should we be unable to reach you directly or leave you a voicemail, please return our call to confirm your appointment, or your appointment will be at risk of being lost.
Macleod Trail Dental Cancellation and No Show Policies
We understand that life can be unpredictable, and unforeseen events may arise and you may need to cancel or reschedule your appointment. We kindly ask that you give us at least 48 hours notice if you need to cancel or reschedule your appointment, to give us the opportunity to offer that time slot to another patient. If 48 hours notice is not provided or you do not show up for your scheduled appointment, we will require a deposit of $100 to schedule another appointment. This deposit will be applied to the cost of your next appointment or reimbursed back to you at the time of the appointment. In the event that you short notice cancel or no show to that appointment the deposit will be forfeited. We understand that emergencies and illness can happen. We will do our best to be understanding in these situations. However, we ask that you please communicate with us as soon as possible if you need to cancel or reschedule your appointment outside of our cancellation policy. Thank you for your understanding and cooperation in keeping our schedule running smoothly. If you have any questions or concerns about our cancellation policy, please do not hesitate to ask us. I have read and understand the above cancellation policy. By signing below, I acknowledge that I am responsible for adhering to this policy and agree to pay the deposit of $100 if I fail to provide the required notice or no show to my appointment.
Patient's Signature
Date
MM slash DD slash YYYY
Macleod Trail Dental Billing Policies
Welcome to Macleod Trail Dental. You have many choices when it comes to choosing a dental office. Everyone at our office is committed to providing quality dental care in a comfortable and safe environment. Please take a few minutes to familiarize yourself with our office’s policies. Although many dental offices are non-assignment, our office will accept direct billing of benefits from your insurance company as part of our patient services. It is important for you to understand that there may be a difference between our fees and what your insurance company will pay for treatment. You are responsible for any difference in fees, with special exceptions for our patients who are covered by a low-income or government assistance plan. The same policy applies to those patients who have coverage through two insurance companies. In order for our office to direct bill with your insurance we do require a form of payment on file in case there is an outstanding balance that could not be collected at the time of the appointment. Once the insurance portion has been collected any balances under $100.00 will be charged to the credit card on file and a receipt will be sent to you. If the charge is over $100.00 you will be contacted by phone or email before the charge is placed. If we do not hear back from you within 2 weeks the charge will be processed on your credit card and a receipt will be sent to you.
Please note that not all procedures will be covered by your insurance or covered exactly to the percentage specified on your plan. Each individual insurance plan has its own fee guides, rules, and exceptions which are negotiated by your employer. These differences are your responsibility to understand and follow. Our office will do our best to assist our patients in understanding the details of their insurance plan; however, we are limited in the information we can access due to privacy laws and it is ultimately the patient’s responsibility to understand their insurance plan, annual maximums, eligible benefits, and covered procedures.
Treatment fees for dental services vary from patient to patient, therefore any and all fee estimates given before being assessed by a dentist and/or hygienist are estimates only and could be substantially more or less at the time of billing. Fee estimates given are only reliable if you have seen the dentist and/or hygienist who has given one of our dental administrators your treatment plan.
We hope that your experience with us will exceed your expectations. If we can help in any way, please do not hesitate to ask.
I give Macleod Trail Dental consent to have my credit card on file and consent to charging the credit card for balances owing after insurance has been collected.
Print Name
Signature
Date
MM slash DD slash YYYY
Credit Card Consent Form
Name
Visa
Mastercard
American Express
Credit Card Number
Expiry Date
MM slash DD slash YYYY
CVV
Signature
Date
MM slash DD slash YYYY
Helcim is a payment processor that lets businesses accept credit cards. All credit card information, including CVV, is stored with the compliant and secure Helcim commerce merchant platform. We store your credit card information into Helcim Card Vault and shred this form.
Consent
I hereby certify that the medical and dental history is accurate and complete, to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics or any drugs as indicated and I will assume responsibility for all fees associated with those procedures. My signature on this form authorizes submission, including electronic submission and direct assignment, where allowed, for claims for dental services provided. I consent to the collection, use and disclosure of personal information as described herein. I have read and understood the foregoing and agree to the terms and conditions stated herein.
Consent
I consent to receiving emails from Macleod Trail Dental
Name
This field is for validation purposes and should be left unchanged.
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