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General Dentistry
Why Choose Us?
Checkups & Cleanings
For Kids
Family Dentist
Emergency Dental Calgary
Senior Dental Care
Sedation for Anxiety
Wisdom Teeth Removal
Sports Mouthguards
Teeth Grinding
Cosmetic Dentistry
What’s Right For Me?
Teeth Whitening
Invisalign
Veneers
Dental Implants
Implant Dentures in Calgary
Botox
TMJ
Sleep Apnea
For Patients
Pricing
Direct Insurance Billing
Our Patient Experience
What To Expect
Forms
Dentist in Acadia
Dental Clinic Fairview
Dentist Calgary SW
Emergency Dental Calgary
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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
*
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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.
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 lost.
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.
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
Email
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