Patient Registration Form

Patient Information

First Name(Required)

Last Name(Required)

Today's Date(Required)

Home Phone

Work Phone

Mobile Phone(Required)

Date of Birth(Required)

Your Gender(Required)

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City Province Postal Code

Occupation(Required)

Place of Business(Required)

Responsible Party

Your Spouse/Parent/Guardian’s Name

His/Her Occupation

His/Her Employer

Name of family member responsible for payment of your account

How did you hear about our office?(Required)

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

Insurance Information

Do you have insurance?(Required)

Yes

Payment Plan

Are you interested in a payment plan for dental services?

Yes

Medical Information

Please note: Prior to any dental treatment, our office requires a complete medical history. Knowing any health problems and/or medications you may be taking can avoid problems when treatment commences. Thank you for taking the time to answer these questions.

Family Doctor’s Name(Required)

Last Medical Exam(Required)

What pharmacy do you use?

Have you ever had a serious injury or major operation?(Required)

Yes

Are you in good health now?(Required)

Yes

Are you presently being treated by a physicians?(Required)

Yes

Are you taking any medications, pills, drugs, or medicine?(Required)

Yes

Allergies: Have you ever had a reaction to any of the following:(Required)

Do you have or have you had any of the following conditions. Please check all that apply:(Required)

Do you get chest pains upon exertion or shortness of breath after mild exercise?(Required)

Yes

Do you get swelling of your ankles or have difficulty lying flat on your back?(Required)

Yes

Do you use controlled substances (cocaine, barbiturates, other)?(Required)

Yes

Have you ever had any excessive bleeding requiring treatment?(Required)

Yes

Do you smoke?(Required)

Yes

Are you pregnant?(Required)

Yes

Is there anything else we should know about your health?(Required)

Yes

Is there a dental problem you would like treated immediately?(Required)

Yes

Are there any other dental condition that concern you at present?(Required)

Yes

Are there any dental issues that you want addressed in the future?(Required)

Yes

How frequently do you see your dentist?(Required)

Date of your last dental visit?

Date of your last dental cleaning?

Date of your last x-rays?

Do you have any other family members that do not have a regular dentist?

Do you have or have you had any of the following conditions. Please check all that apply: (Choose as many as you like)(Required)

Periodontal Treatment (treatment of the gums)

Orthodontics Treatment (to straighten or realign teeth)

A Bite Plate, Night Guard or Other Appliance

Dentures or partial dentures

Wisdom teeth removed

Root canal treatment

Crown or bridge

None of the above

Have you ever had any injury, surgery, or x-ray therapy to the face or jaw?(Required)

Yes

Are there any growths or sore spots in your mouth?(Required)

Yes

Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums?(Required)

Yes

Have you been given oral hygiene instruction in brushing, flossing or other instructions?(Required)

Yes

Have you noticed any loose teeth, or, have any of your teeth shifted?(Required)

Yes

Does food catch between your teeth?(Required)

Yes

Are any of your teeth sensitive to heat, cold, sweets or pressure?(Required)

Yes

Have you ever experienced any of the following jaw problems: Please check all that apply: (Choose as many as you like)

Popping/clicking in your jaw joints.

Pain in your jaw joints, around your ear or side of your face.

Difficulty opening or closing.

Pain when teeth are clenched.

Pain or difficulty while chewing.

None of the above.

Do you have any of the following habits? Please check all that apply: (Choose as many as you like)

Clenching or grinding your teeth while awake or asleep?

Biting your cheeks or lips?

Mouth breathing while awake or asleep?

Gag reflex?

None of the above.

Are you missing any teeth?(Required)

Yes

Are you dissatisfied with the appearance of your teeth?(Required)

Yes

What would you like to see improved if anything?

Are you interested in discussing any of the following with the dentist or hygienist?

Teeth whitening or bleaching?

Cosmetic dentistry?

Orthodontic treatment?

Have you ever had local anesthetics (freezing)?(Required)

Yes

Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment, or, do you have any questions or concerns?(Required)

Yes

Have you had dental x-rays taken in the last 5 years?(Required)

Yes

Personal Information Consent Form

Privacy Policy

We are committed to protecting the privacy of our patients’ personal information. Collecting, using and disclosing all personal information will be done in a responsible and professional manner and in accordance with The Personal Information Protection and Electronic Documents Act and Health Information Act.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell phone numbers, and e-mail addresses. (Collectively referred to as “Contact information”) Contact Information is collected, shared with all family members and used for the following purposes:

To open and update patient files.
To invoice patients for dental services, process credit card payments, or collect unpaid accounts.
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
To send reminders to patients concerning the need for further dental examination or treatment.
To send patients informational material about our dental practice.
To confirm appointments.

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.

Medical Information

We collect information from our patients about their health history, family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”). This information is used for diagnosing dental conditions and providing treatment.

Patients’ Medical Information may be disclosed:

To third party health benefit providers and insurance companies for claims.
To other dentists and dental specialists with patient consent (e.g., referrals or second opinions).
To other healthcare professionals such as physicians with patient consent.

The Health Information Act facilitates sharing of health information within a “circle of care” (dentists, specialists, physicians, Alberta Health and Wellness, Alberta Health Services). Disclosure outside this circle is strictly controlled. Patients may restrict disclosure at any time.

Additional Notes

If the practice is ever sold, qualified purchasers may access patient information under safeguards during due diligence. The Alberta Dental Association and College may inspect records as part of regulatory activities.

Consent

By signing, I consent to the performance of necessary dental procedures, and the collection, use, and disclosure of my personal information as outlined above. I also consent to the use of images/videos (excluding dental records/x-rays) for promotional purposes. In compliance with Canadian Anti-Spam Laws, I consent to receive appointment reminders, confirmations, news, and events.

Information Retention & Access

We retain personal information as long as necessary for oral health services and administration, and securely destroy it when no longer needed. Patients may request access or amendments to their records in writing at any time.

Complaints & Contact

To make a complaint regarding privacy practices, please contact our Office Manager, Swita Zaher. Questions or concerns may also be directed to her.

Financial Policy & Agreement

Thank you for choosing us for your dental needs. Our financial arrangements are based on open discussions of treatment options, fees, and patients’ financial abilities.

Treatment Disclaimer

We ensure patients are well-informed about treatments and costs. In cases of additional charges, we will:

Explain the reason for additional treatment.
Provide a detailed quote upon request.
Check insurance coverage before proceeding.

Patients are responsible for understanding their insurance coverage and out-of-pocket expenses.

Dental Insurance

We accept assignment of benefits and prepare forms, but insurance contracts are between the patient and their provider. Coverage varies greatly, and delays may occur. Pre-treatment estimates can be submitted upon request.

Payment Options

We accept Cash, Debit, Visa, MasterCard, and American Express. Payment is due at the time of service. Extensive treatment may qualify for financial arrangements.

Payment Plans

No-interest payment plans are available (not for first visits):

35% due at service.
Balance split over 3 months (credit card required).
$50 NSF fee + 8.5% interest for failed payments.

Financial Consent

Unpaid balances over 90 days without arrangements are sent to collections. Claims and pre-authorizations may be sent electronically. Patients are ultimately responsible for unpaid balances regardless of insurance.

Appointments

Reserved appointment times require 2 business days’ notice for cancellation.

Cancellation & No-Show Policy

Cancellations with less than 2 business days’ notice or missed appointments incur a $100 fee.
First missed fee may be waived.
Repeated no-shows may lead to dismissal from the clinic.
Fees billed to credit card on file or due before next visit.

Late Arrivals

Please call if running late.
Arrivals 15+ minutes late may need to reschedule.

We appreciate your cooperation in helping us provide timely and effective care to all patients.

Date(Required)

Patient Name(Required)

Signature of Patient or Guardian(Required)

Monday	8am - 8pm
Tuesday	8am - 8pm
Wednesday	8am - 8pm
Thursday	8am - 8pm
Friday	8am - 4pm
Saturday	8am - 4pm
Sunday	9am - 4pm