Click on Calendar, type the year 'YYYY' and pick the month & date.

*Patient Name :

Last name

First name

Mid name

Birthday :

Age:

Gender : Male Female Other

*Address:

				City
Province		Postal		APT#

*Email Address:

*Home phone #:

()- -

Cell phone #:

()- -

Work phone #:

()- - -

Are there any records or X-rays we should request from your previous dentist? Yes No

Previous dentist's name :

Dentist address:

				City
Province		Postal		APT#

Insurance information

Primary Insurance

Card Holder :

Birthday :

Insurance Co. Name:

Group #:

ID # :

Employer :

Secondary Insurance

Card Holder :

Birthday :

Insurance Co. Name:

Group # :

ID # :

Employer :

Medical History

When was your last dental exam? /

Dr.’s Name :

When did you last have your teeth professionally cleaned? /

Dental x-rays? /

When was your last medical examination? /

Family Dr. Name :

*How did you hear about us?

Other Health care practitioners you see :

Name	Telephone
	()- -
	()- -
	()- -

Can we notify them about today's findings to better treat your entire body's needs? Yes No

Is your health compromised? Yes No

Are you taking any medications now (baby aspirin etc.)? Yes No

Please list :

Are you taking any vitamins or herbal supplements? Yes No

Please list :

Serious illness, hospitalization, or operation in the last 5 years? Yes No

Please list :

Do you use tobacco or vaping products? Yes No

Amount :

Are you pregnant? Yes No

Are you taking hormonal birth control products? Yes No

Are you taking hormone medications? Yes No

Have you any allergies to the following?

Antibiotics

Metals

Pain killers

Latex

None

Please list any other drugs / materials that you are allergic to :

Do you have any disease, medical condition or problem not listed above?

TELL US ABOUT YOUR ORAL HEALTH

Are you nervous about visiting our office? Yes No

Are you in dental pain right now? Yes No

Do you have sensitive teeth? Yes No

What do you do everyday to clean your teeth?

Other cleaning aids used & how often?

Do your gums bleed when you brush or floss? Yes No

Do you feel you have bad breath? Yes No

May we teach you our cure for flossing guilt? Yes No

Would you like to know when your teeth are clean enough? Yes No

Does your jaw get “stuck”, “locked”, or “go out”? Yes No

Have you ever injured your jaw, head or neck? Yes No

Do you ever have pain opening or closing your mouth? Yes No

Do you clench or grind your teeth? Yes No

Are you worried about toxicity of your mercury (grey) fillings? Yes No

Do you choose fillings based on?
(Please list in order of importance the following 1 - More Important, 3 - Less Important)

Appearance Durability Cost

Are you hard to freeze? Yes No

Have you ever had a reaction to local anesthetic? Yes No

Are you unhappy with the color of your teeth? Yes No

Are you missing any teeth? Yes No

Would you like your teeth to be straighter? Yes No

Would you straighten your teeth if you didn’t need to wear braces? Yes No

If you could change anything about your smile what would it be?

Do you snore? Yes No

Do you fall asleep easily (while watching TV, during meetings etc.)? Yes No

Do you wake up most mornings not feeling refreshed? 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 to which Living Wellness Dental practitioners may choose to refer 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.

New Patient Registration
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