Suite 2300, 8561 – 8A Avenue SW, Calgary, AB T3H 0V5

(403) 727-5307
info@westcalgaryperio.ca

Refer A Patient

Patient Form

West Calgary Periodontics New Patient Form

Welcome to West Calgary Periodontics

To save time at your appointment please complete the form below. Fields with a * indicate required.

If you have any questions about this form, please contact our office.

    Date Signed:

    Patient Contact

    Name

    Birth Date
    Gender
    Address
    Email
    Home Number
    Cell Number
    Other

    By which method do you prefer our office to contact you ?

    Home PhoneMobile phoneTextEmail

    Consent For Release of Information to Dental Insurance Provider

    Please complete only if you have dental insurance

    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

    (To draw signature press and hold mouse button while moving mouse over signature field)

    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 Name & Date of Birth

    Policy Holder Name & Date of Birth

    Medical History

    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
    (4) Have you ever have had an abnormal reaction to any medications or injections?
    YESNO
    (5) Have you ever had an abnormal reaction to anesthetic or general anesthetic?
    YESNO
    (6) Have you ever been advised by a doctor/dentist to take antibiotics before dental treatment?YESNO
    (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
    If yes , please list them all:
    (12) Please provide your Height
    cm
    Weight kg
    (13) Do you smoke or use tobacco / cannabis products?YESNO
    (e.g. number of cigarettes or vaporizer uses during the day)
    (14) Is there a history of early tooth loss in your family?YESNO
    (15) Are you nervous about dental treatment?YESNO
    On a scale of 1 to 10 (1 not nervous, 10 very nervous). Please indicate how nervous you feel about dental treatment.

    For Women only
    (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:

    Use and Transfer of Clinical Images Consent

    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

    (To draw signature press and hold mouse button while moving mouse over signature field)

    Date Signed

    Contact Us

    Quick Contact Form

    Please Do Not Use This Form To Cancel Or Reschedule An Existing Appointment

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      (403) 727-5307

      Suite 2300, 8561 – 8A Avenue SW, Calgary, AB T3H 0V5

      info@westcalgaryperio.ca

      (403) 727-5278

      Opening Hours

      Monday: Closed

      Tuesday to Friday: 8:00am to 4:00pm

      Weekends & Statutory Holidays: Closed

      Parking

      Plenty of Free Onsite Parking

      Accessibility

      West 85th Professional Building is Wheelchair Accessible including Elevator & Washrooms

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

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