Patient Forms - West Calgary Periodontics

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I, (PRINT NAME), authorize release, to my dental benefits plan administrator and the Canadian Dental Association (CDA), information contained in claims submitted electronically. 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.

Signature of person authorizing release

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Dental Insurance Policy #1 Photos
(front and back of card)

Note: You can upload a total file size of up to 20MB.
Please upload only jpeg|png|jpg|pdf file type.

Dental Insurance Policy #2 Photos
(front and back of card)

Note: You can upload a total file size of up to 20MB.
Please upload only jpeg|png|jpg|pdf file type.

Policy Holder Date of Birth

The following information is required to provide you with the best dental care. All information that you provide is kept strictly confidential. If you do not understand a question. please contact our office for clarification.

(1) Do you have regular check-ups with your family doctor?YESNO

Name of Physician

Physician Telephone#

(2) Do you take any medications, non-prescription drugs or herbal supplements?YESNO

If yes, please list them all including dosages and how frequently you take them:

(3) Have you ever or are you currently taking any oral medications (e.g Etidronate(Didrocal), Alendronate (Fosamax), Risedonate (Actonel) or any IV medications (e.g Zoledronicacid (Reclast) or Ibandronate (Bonita) for your bones including for osteoporosis, bone pain, Hypercalcemia, Paget’s disease, multiple Myeloma or Metastatic cancer?YESNO

If yes, please list the medications, how often you take them, when last taken, and reason for taking them:

(4) Have you ever have had an abnormal reaction to any medications or injections?
YESNO

If yes, please list the medications or injections that caused the reaction, and the type of reaction you experienced:

(5) Have you ever had an abnormal reaction to anesthetic or general anesthetic?
YESNO

if yes, please list the anesthetic or procedure you were undergoing when the reaction occurred, and the type of reaction you experienced:

(6) Have you ever been advised by a doctor/dentist to take antibiotics before dental treatment?YESNO

if yes, please list the antibiotics and the reason for taking them:

(7) Have you ever been hospitalized for any illness or operation?YESNO

If yes, please list them all:

(8) Do you have any allergies?YESNO

If yes , please list them all:

(9) Do you, or have you had in the past, any of the following?

Alcohol dependencyAnemiaArthritisArtificial jointsArtificial heart valveBleeding disordersCancerChemotherapyChest pain (Angina)

DiabetesDrug dependencyFainting spellsGastric reflux ( GERD)Heart attackHeart diseaseHeart murmurHemophiliaHigh blood pressure

Irritable bowl syndromeKidney diseaseLeukaemiaLiver diseaseOrgan transplantOsteoporosisPacemakerRadiation therapyRemoval of spleen

Rheumatic feverSeizures (epilepsy)Shortness of breathSickle cell diseaseSleep apneaSteroid therapyStomach ulcersThyroid diseaseTuberculosisNone of the Above

(10) Do you, or have you in the past, any conditions or diseases not listed above?YESNO

If yes , please list them all:

(11) Are there any medical conditions that run in your family (e.g diabetes, heart disease)?YESNO

Yes, please list the medical conditions and which family members are affected:

(13) Do you smoke or use tobacco / cannabis products?YESNO

if yes, please list number of cigarettes smoked per day, or frequency of vaporizer use and concentration of vape liquid vaped:

If yes, how many years have you been smoking / vaping?:

(14) Is there a history of early tooth loss in your family?YESNO

If yes, please list which family members are affected:

On a scale of 1 to 10 (1 not nervous, 10 very nervous). Please indicate how nervous you feel about dental treatment.

(16) Are you pregnant or suspect that you may be pregnant?YESNON/A

(17) Are you nursing?YESNON/A

(18) ADDITIONAL INFORMATION - Is there any additional information that you would like to provide:

I give consent for clinical images (photographs and x-rays) to be taken of me, or of my child, or of a person for whom I am a legal guardian. I understand clinic images form part of my dental record. I understand that duplicates may be sent to the referring dentist/physician, as part of my treatment. At times, additional consolation/interpretation of the images may be required as part of my treatment. In such circumstances, Dr. Tom Wierzbicki will be required to send off the images, and relevant demographic and medical information to a third party health care provider (e.g. radiologist) for consultation. The images may be transferred by hard copy (e.g. CD) sent by mail, or electronic submission over the internet.

Furthermore, I understand that the clinical images, with my consent, may be used for the purposes of dental/medical training, research, teaching, publication in dental/medical textbooks or journals, or used for marketing of the clinic. I understand that if used for these purposes, the images will not contain any identifying information such as my name, but that it may still be possible that someone recognize me.

I acknowledge that I will not receive compensation for the use of the clinical images.

I understand that I have the right to withdraw consent at any time by written request to Dr. Tom Wierzbicki or West Calgary Periodontics staff.

I understand that refusal to consent to the use of clinical images will in no way affect the dental care I receive.

Please check Yes or No below to show type of consent given:

Transfer to third party health care provider for consultation/interpretation YESNO

For education, research, and teaching purposes YESNO

In paper or electronic health publications (e.g. dental journals) YESNO

In marketing materials (e.g. patient pamphlets, website) YESNO

By signing below, I confirm that I understand this consent form, and had any questions related to it answered to my satisfaction.

Signature of Patient/Parent or Guardian

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Date Signed

Call us at (403) 727-5307 to schedule your appointment today!
No referral is necessary.

Patient Form

West Calgary Periodontics New Patient Form

Patient Contact

Consent For Release of Information to Dental Insurance Provider

Dental Insurance Policy #1 Photos
(front and back of card)

Dental Insurance Policy #2 Photos
(front and back of card)

Medical History

Use and Transfer of Clinical Images Consent

Contact Us

Quick Contact Form

Opening Hours

Parking

Accessibility

Patient Form

West Calgary Periodontics New Patient Form

Patient Contact

Consent For Release of Information to Dental Insurance Provider

Dental Insurance Policy #1 Photos(front and back of card)

Dental Insurance Policy #2 Photos(front and back of card)

Medical History

Use and Transfer of Clinical Images Consent

Contact Us

Quick Contact Form

Opening Hours

Parking

Accessibility

Dental Insurance Policy #1 Photos
(front and back of card)

Dental Insurance Policy #2 Photos
(front and back of card)