New Patient Form | Erin RIdge Dental

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Are you a new patient?

Fill in your information below so we know who you are!

Step 1 of 6 - Personal Information

16%

Name*
First Name Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Email*
Home Phone*
Cell Phone*
Address
Street Address City Province Postal Code
Gender*
- Male
- Female
- Other
Emergency Contact*
Emergency Contact Number*
How did you hear about us?*

Employer*
Occupation*
Do you have Dental Insurance?*
- Yes
- No
Name of Dental Insurance Subscriber*
First Name Last Name
Date of Birth of Subscriber*
Date Format: MM slash DD slash YYYY
Name of Insurance Provider*
Group/Plan Number*
Certificate/ID Number*
Do you have a second Insurance Provider?*
- Yes
- No
Name of Dental Insurance Subscriber*
First Name Last Name
Date of Birth of Subscriber*
Date Format: MM slash DD slash YYYY
Name of Insurance Provider*
Group/Plan Number*
Certificate/ID Number*

What's your main concern right now?*
When was your last dental visit?*
Previous Dental Office*
Do your Gums feel tender/swollen?*
- Yes
- No
Do your Gums bleed?*
- Yes
- No
Do you have bad breath or a bad taste in your mouth?*
- Yes
- No
Have you had excessive bleeding during past dental visits?*
- Yes
- No
Do you grind/clench your tooth or notice any popping/clicking noises?*
- Yes
- No
Do you wear a night guard?*
- Yes
- No
Do you suffer from frequent migraines?*
- Yes
- No
Is snoring a problem for you?*
- Yes
- No
Are you happy with the way your smile looks?*
- Yes
- No

Do you have any serious Medical Conditions we should know about?*
- Yes
- No
Please explain.
Known Medical Conditions
- No Known Medical Issues
- Alcohol/ Drug Abuse
- Angina
- Arthritis
- Asthma
- Blood Disorder
- Cancer
- Chemotherapy
- Congenital Heart Defect
- Diabetes
- Dizziness/Fainting
- Emphysema
- Epilepsy/Seizures
- Frequent Headaches
- Gag Reflex
- Hay Fever
- Head Injuries
- Hearing Disabled
- Heart Attack
- Heart Murmur
- Hemophilia
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
- Hepatitis A/B/C
- High Blood Pressure
- HIV/AIDS
- Joint Replacement (hip, knee, etc)
- Kidney Disease
- Liver Disease
- Low Blood Pressure
- Lung Disease/ Tuberculosis
- Mental Disorder
- Mitral Valve Prolapse
- Multiple Sclerosis
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Sinus Problem
- STD
- Stomach/Intestinal Problems
- Stroke
- Thyroid Disorder
- Ulcer
- Other
If Other selected, please specify:*
Do you have any allergies to medication or substances?*
- Yes
- No
What Allergies do you have?
Are you taking any prescription medication or herbal remedies?*
- Yes
- No
Please list off your medications*
Do you need to be medicated with antibiotics prior to dental treatment*
- Yes
- No
Do you smoke or use chewing tobacco?*
- Yes
- No
Have you ever been treated for any other illness not listed above?*
- Yes
- No
If Yes selected, please specify:*
Are you pregnant and/or nursing?*
- Pregnant
- Nursing
- No
How far along is your pregnancy?*

Have you recently been under the care of a physician?*
- Yes
- No
Name of Physician*
Physician's Phone Number
When was your last visit with the physician?*
Current Health Condition*
- Excellent
- Good
- Fair
- Poor

Is there any other information you want to tell us?
Consent*
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 it is my responsibility to inform this office of any changes to my health or medical status. I authorize Parkway Smiles Dental to preform any necessary dental services that I may need.
Signature*
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Dr. Lorne Wasylucha and Associates

975 St Albert Trail #110, St. Albert, AB T8N 4K6

Phone: (780) 569-5151

Email: info@erinridgedental.ca

Our Hours

Mon	8:00 AM – 4:00 PM
Tues	8:00 AM – 4:00 PM
Wed	10:00 AM – 6:00 PM
Thurs	10:00 AM – 6:00 PM
Fri	8:00 AM – 3:30 PM
Sat-Sun	Closed

Closed on holidays and long-weekends.

Serving St. Albert and Surrounding Communities

ERIN RIDGE NORTH	INGLEWOOD
JENSEN LAKES	VILLE GIROUX
ERIN RIDGE	MISSION
OAKMONT	BRAESIDE
DEER RIDGE	WOODLANDS
NORTH RIDGE	KINGSWOOD
LACOMBE PARK	PINEVIEW
ST. ALBERT	STURGEON COUNTY
MORINVILLE	CARDIFF

© 2020 Erin Ridge Dental

About Us
Services
Contact
- Contact Us
- Our Forms
  - New Patient Form
  - X-Ray Release Form