CLICK HERE TO Refer a patient to NW Endodontics
Please Also Complete Our Office Policies Form
Name
Address
Birthdate
Telephone
Email Address
Alberta Health Care #
Emergency Contact
Insurance Company
Name of Subscriber
Date of Birth
Group or Plan #
Identification #
Name of Employer
Family Physician
Physician Phone
Are you currently under the care of a physician? YESNO
if yes, please explain:
Have you been hospitalized for major surgery? YESNO
if yes, please describe:
Do you have any health problems that require further clarification? YESNO
Have you ever had any complications following dental treatment? YESNO
Anemia YESNO
Arthritis / Rheumatoid Arthritis YESNO
Artificial Heart Valve / Pacemaker YESNO
Asthma YESNO
Blood Pressure: HIGHLOWN/A YESNO
Blood Disorder YESNO
Cancer YESNO
Diabetes: TYPE1TYPE2N/A YESNO
Emphysema YESNO
Epilepsy / Seizures YESNO
Gag Reflex YESNO
Glaucoma YESNO
GI troubles / IBS / Colitis YESNO
Head Injuries YESNO
Heart Condition YESNO
Hepatitis: ABCN/A YESNO
HIV / AIDS YESNO
Joint Replacement (hip, knee, etc.) YESNO
Kidney Disease YESNO
Liver Disease YESNO
Lung Disease YESNO
Mitral Valve Prolapse YESNO
Multiple Sclerosis YESNO
Neurologic Problems YESNO
Osteoperosis YESNO
Radiation / Chemotheropy YESNO
Respiratory Problems YESNO
Rheumatic Fever YESNO
Stroke YESNO
Thyroid Condition YESNO
Tubercolosis YESNO
Tumors YESNO
Ulcers YESNO
Please list any other serious medical conditions you have or had in the past:
Please list any current medication(s) you are taking:
Do you have a medical condition that requires a Pre-Medication prior to dental treatment? YESNO
Penicillin YESNO
Sedatives YESNO
Erythromycin YESNO
Sulfa Drugs YESNO
Metals YESNO
Latex YESNO
Tetracycline YESNO
Codeine YESNO
Keflex YESNO
Aspirin Drugs YESNO
Local Anesthetic YESNO
Ibuprofen YESNO
ADDITIONAL KNOWN ALLERGIES:
Are you taking any Birth Control Medication? YESNON/A
Are you Pregnant? YESNON/A
Are you Nursing? YESNON/A
As the patient (or legal guardian) you are responsible for full payment of any services received on the day of service regardless of insurance coverage. We DO NOT accept payment from insurance companies. Full payment must be made to our office by the patient or guardian. Any insurance reimbursement will go directly to the plan holder.
I authorize the release of information to my dental benefits plan administrator and the Canadian Dental association information contained in claims submitted (electonically). I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.
