Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Registration
Print blank form to fill by hand


  Last name

  First name

  Mid name
    
    
Male Female
*Address:
City
State
Postal
APT#
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Yes No
Previous dentist's name :
Dentist address:
City
State
Postal
APT#
*Whom may we Thank for referring you?

Insurance information

Primary Insurance

Secondary Insurance

Medical History

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/
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Name Telephone
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()- -
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Heart Disease
Rheumatic/Scarlet Fever
Artificial joints/Heart Valves
Stroke
Abnormal Bleeding/ Blood disorders
Fainting Spells
Diabetes
Hepatitis
Kidney or Liver Disease
Digestive Challenges
Irritable Bowel Syndrome
Colitis
Crohn’s Disease
Stomach Ulcers
HIV/ AIDS
Herpes / Cold sores / Mouth sores
Asthma/ Breathing problems
Tuberculosis
Epilepsy/ Seizures
Frequent or Severe Headaches?
Neck or shoulder pain?
Cancer
Radiation Treatment
Nervous/ Mental Disorders
Blood clots
Osteoporosis
Low blood pressure
High blood pressure
Alcohol/Drug Abuse
Arthritis
None of the above
Antibiotics
Metals
Pain killers
Latex
None


Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Appearance      Durability      Cost
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Yes No
Yes No
Yes No

Consent for Treatment & Privacy Disclosure

We are committed to protecting the privacy of your personal information and to utilizing all personal information in a responsible and professional manner. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law. Common ways we use and collect personal information are listed below: Contact information is disclosed to third party health benefit providers and insurance companies when a 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 their behalf. It is also used to invoice for dental services, to collect unpaid accounts or to remind patients concerning the need for further treatment. Financial information may be collected in order to make arrangements for the payment of dental services. Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. It may also be disclosed to other dentists and/or specialists for procedures that Dr. Robertson or Dr. Redd may choose to refer to them. If selling all or part of our dental practice, qualified potential purchasers may be granted access 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.
* This is to certify that I consent to the dental procedures agreed to be necessary or advisable for myself, or my child, including the use of local anesthetic or other drugs as indicated and I will assume responsibility for fees associated with those procedures. I consent to the collection, use and disclosure of my personal information as set out above.

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)