Patient History Form

Dr. Laurie-Anne Wilson D.M.D.

15, 8 Weston Drive SW Calgary AB T3H 5P2

403-686-7266

westspringsdental@shaw.ca

Full Name *

First

Last

If patient is a minor, who is legally responsible?

all open disorders

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth *

Cell Phone Number

Home Phone Number

Email Address

How do you prefer to receive your appointment notifications?

Text message
Email

How did you hear about our office? *

Employer

Physician *

Previous Dentist/ Dental office

Would you like your records requested from the previous office?

Please indicate YES or NO: Do any of the following conditions apply to you? (past or present)

If you have any disease, condition or problem not listed above, please specify

Are you under the care of a physician for a current problem? *

Are you currently taking any prescription or non-prescription medication, including herbal supplements? *

Please list them.

Have you had any ALLERGIES or ADVERSE REACTIONS to anaesthetics, antibiotics, latex or medications? *

Yes
No
Not Sure

Please list them.

Has there been any change in your general health in the past year? *

Do you smoke, vape, or use chewing tobacco? *

Have you had abnormal bruising or bleeding? *

Does your physician require you to take antibiotics prior to dental treatment? *

Have you been hospitalized in the last 5 years? *

Women: Are you pregnant?

Women: Are you breastfeeding?

Women: Do you take birth control pills? If YES, please be advised that if you take antibiotics an alternate method of birth control must be used.

What is the reason for today's visit? *

Emergency/ urgent care
Examination
Cleaning/ hygiene
Other

How frequently do you see a dentist? *

3 – 6 months
Annualy
Other

When was your last dental visit? *

When was your last dental xrays? *

How many times per day to you brush your teeth? *

Floss? *

Mouthwash/ rinse? *

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

Do your jaws crack, pop, or grate when you open widely? *

Are you aware that you grind or clench your teeth? *

Have you ever had local anaesthetic (freezing)? *

Have you had any issues with previous dental treatments? *

Are you satisfied with your teeth? *

If you could change one thing, what would it be? *

CONSENT FOR TREATMENT

I understand that I have provided accurate and complete information to the best of my knowledge, and agree to update the office with any changes. I understand that providing incorrect or incomplete information can affect my dental care and results, and may be dangerous to my health. I authorize the dentist to release any information necessary to my insurance carrier and/or health providers. I understand my recommended treatment is for my ideal oral care, and that my dental plan may not cover all procedures or fees. I am aware that the dental office may not be able to pertain if and what will be covered by my dental insurance plan. I agree that I am responsible for payment for all services rendered for myself and my dependants.

Signature *

Clear Signature

Date *

FINANCIAL INFORMATION

Our dental team is committed to providing efficient handling of your dental care and insurance paperwork. Due to the wide variety of insurance plans and coverage options, we do not accept direct assignment of insurance plan payments on your behalf.

1. Westsprings Dental will submit your insurance claims on your behalf whenever possible, and your insurance company will reimburse you their covered amount. Electronic billing is very efficient, and there will be little or no paperwork for patients. The patient is responsible for the cost of their dental visit on the date of service, and we accept Visa, Mastercard, American Express, Debit or Cash.

2. It is the patient’s responsibility to be aware of the coverage details and limitations, and to inform us of any changes. Our knowledgeable staff will be happy to provide assistance and help with any questions or concerns.

3. As per the privacy act, we require your signature as consent to the collection, use, or disclosure of personal information, as is necessary for the patient’s dental care. This allows us to electronically submit your dental claims.

4. We would prefer that you pre-book any follow-up appointments prior to your departure to ensure continuity of care.

I consent to the collection, use and disclosure of my personal information, as set out above. I understand and consent to the office payment policy described.

Signature *

Clear Signature

Name of person signing *

Date *