4812 50 Ave, Provost, AB T0B 3S0, Canada
(780) 753-2430
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(780) 753-2430
Home
Meet our Doctor
About
Services
Forms
Contact
X
Forms
Adult NPE form Medical History
Patient's First Name
Patient's Last Name
Email
Phone
Appointment Day
Appointment Time
Requested Appointment
Check up and cleaning
Check up only
Cleaning only
Emergency
Send
First Name
Last Name
Date of birth
Address
Phone number
Email
Have you been under the care of a physician recently? If so please indicate date of last visit:
yes
No
Unsure
Have you ever had a serious illness? If so, please specify:
yes
No
Unsure
Have you ever had any type of Allergy, Hay Fever and Asthma? If yes, please list allergen(s) and reaction(s):
yes
No
Unsure
Have you ever had reaction to a drug? If yes, please specify:
yes
No
Unsure
Are you taking any medication at present? If yes, please list:
yes
No
Unsure
Are you taking a blood thinner? Please list:
yes
No
Unsure
Additional Medications
Have you ever fainted?
yes
No
Unsure
Do you bleed easily or do cuts in your skin stay open for a long period of time?
yes
No
Unsure
Do you have any pains in the chest?
yes
No
Unsure
Have you ever had any of the following
Heart Disease
yes
No
Unsure
High Blood Pressure
yes
No
Unsure
Diabetes
yes
No
Unsure
Kidney Disease
yes
No
Unsure
Hepatitis(A, B, etc.)
yes
No
Unsure
Epilepsy
yes
No
Unsure
Have you ever had any injury, surgery or X-ray therapy to the face or jaws?
yes
No
Unsure
If yes, please list surgery and date
Have you ever had any injury, surgery or X-ray therapy to the face or jaws?
yes
No
Unsure
Anything else you would like us to know about you?
Adult NPE form Dental History
When was the last time you visited your previous dentist?
Is there anything we can do to improve your dental experience?
How do you feel about your smile on a scale of 1-10 (with 10 being excellent)
If comfortable, please tell us why you left your previous dental home
I, the undersigned, have completed the above questionnaire and/or update and that it is accurate to the best of my knowledge. I also certify that I consent to the performing of dental treatment and procedures agreed to be necessary or advisable. I also agree to assume responsibility for fees associated with those procedures. I understand that during the course of treatment, unexpected difficulties may arise, resulting in an altered prognosis, or a change of proposed treatment. I also consent to the taking of diagnostic photographs or radiographs agreed to be necessary. I also consent to be contacted by email.
Additional Comments
Send
Adult NPE Form (Medical and Dental)
Dental History
When was the last time you visited your previous dentist?
Is there anything we can do to improve your dental experience?
How do you feel about your smile on a scale of 1-10 (with 10 being excellent)
If comfortable, please tell us why you left your previous dental home
I, the undersigned, have completed the above questionnaire and/or update and that it is accurate to the best of my knowledge. I also certify that I consent to the performing of dental treatment and procedures agreed to be necessary or advisable. I also agree to assume responsibility for fees associated with those procedures. I understand that during the course of treatment, unexpected difficulties may arise, resulting in an altered prognosis, or a change of proposed treatment. I also consent to the taking of diagnostic photographs or radiographs agreed to be necessary. I also consent to be contacted by email.
Send
