New Patient Form

Step 1 of 7 - Personal Information

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Name*

First Name Last Name

Email*

Home Phone

Cell Phone*

Date of Birth*

Gender*

Address*

Street Address City Province Postal Code

Emergency Contact*

Emergency Contact Number*

How did you hear about us?*

Employer*

Occupation*

Do you have Dental Insurance?*

Yes

Insurance Provider*

Group/Plan Number*

Certificate/ID Number*

Name of Dental Insurance Subscriber*

First Name Last Name

Date of Birth of Subscriber*

Do you have a second Insurance Provider?*

Yes

Secondary Insurance Provider*

Group/Plan Number*

Certificate/ID Number*

Name of Dental Insurance Subscriber*

First Name Last Name

Date of Birth of Subscriber*

What's your main concern right now?*

When was your last dental visit?*

Previous Dental Office*

Patient's Dental Concerns

The following questions help us to understand your needs and concerns. Please check any that apply.

Do your gums feel tender/swollen?

Do your gums bleed?

Do you have bad breath or a bad taste in your mouth?

Have you had excessive bleeding during past dental visits?

Do you grind/clench your tooth or notice any popping/clicking noises?

Do you wear a night guard?

Is snoring a problem for you?

Are you happy with the way your smile looks?

Do you have any serious Medical Conditions we should know about?*

Yes

Please explain.

Known Medical Conditions Please select each medical condition that is applicable to you.

Medical Conditions

Please select each medical condition that is applicable to you.

Alcohol/Drug Abuse

Anemia

Angina

Anxiety Attacks

Arthritis

Artificial Heart Valve

Asthma

Blood Disorder

Cancer

Chemotherapy

Congenital Heart Defect

Diabetes

Dizziness/Fainting

Emphysema

Epilepsy/Seizures

Frequent Headaches

Gag Reflex

Glaucoma

Hay Fever

Head Injuries

Hearing Disabled

Heart Attack

Heart Disease

Medical Conditions Continued

Heart Murmur

Hemophilia

Hepatitis A B C (circle)

High Blood Pressure

HIV/AIDS

Joint Replacement (hip, knee, etc.)

Kidney Disease

Liver Disease

Low Blood Pressure

Lung Disease/Tuberculosis

Psychological Disorder

Mitral Valve Prolapse

Multiple Sclerosis

Pacemaker

Radiation Therapy

Respiratory Problems

Rheumatic Fever

Sinus Problem

STD

Stomach/Intestinal Problems

Stroke

Thyroid Disease

Ulcer

Please list any other medical conditions you may have:

Do you have any allergies to medication or substances?*

Yes

What Allergies do you have?

Are you taking any prescription medication or herbal remedies?*

Yes

Please list off your medications*

Do you need to be medicated with antibiotics prior to dental treatment?*

Yes

Please list off the medications that are needed

Do you smoke or use chewing tobacco?*

Yes

Have you ever been treated for any other illness not listed above?*

Yes

If Yes selected, please specify:*

Are you Pregnant?*

Yes

How far along is your pregnancy?*

Are you Nursing?*

Yes

Have you recently been under the care of a physician?*

Yes

Name of Physician

Physician's Phone Number

When was your last visit with the physician?*

Current Health Condition*

Excellent

Good

Fair

Poor

Please consent to the following statements

Consent*

I consent to the information in this New Patient Form

If you require pre-authorization, it is the responsibility of the patient to request our office to complete one on your
behalf. Our office will only complete one on your behalf once the corresponding appointment is booked due to the amount of time and work that goes into each pre-authorization. Once the pre-authorization has been assessed by
your insurance, it will then be forwarded to your policyholder. Our office will not receive a copy unless it is provided to us by the patient. Please either email, fax or drop off a copy to our office so that we may assess the
accuracy of the pre-authorization. At that time we would be more than happy to complete a breakdown of your coverage so that you are aware of your estimated payment from insurance.

Is there any other information you want to tell us?

Consent*

I consent to the information in this New Patient Form

I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence, and I am responsible for informing this office of any changes to my health or medical status. I authorize Quarry Park Dental to preform any necessary dental services that I may need.

Signature*

Your Name
Your Name
Your Name

Dentistry Made Simple.

Thanks For Filling Out Our Form.

Family Dentist Serving The SE Calgary Communities of:

Day of the week	Opening Hours
Monday	9 am – 5 pm
Tuesday	9 am – 5 pm
Wednesday	9 am – 7 pm
Thursday	9 am – 7 pm
Friday	8 am – 3 pm
Saturday	9 am – 3 pm
Sunday	Closed