New Patient Intake Form

"*" indicates required fields

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Name*

First Middle Last

Birthdate*

Age*

Address*

Street Address City Province Postal Code

Email*

Home Phone*

Work Phone

Cell Phone

Occupation

Employer

Family Doctor

Family Doctor's Phone

Emergency contact

How did you hear about us?*

Postcard

Yellow Pages

Smile Insider

Website

Walk-by

Northern Edge Newsletter (community)

Other

Description*

Friend/Family Referral (name)

Dental Insurance Information

Insurance Company #1

Yes

Insurance Company #1*

Policy/Group #*

ID #*

Policy Holder's Name*

Policy Holder's Birth Date*

Insurance Company #2

Yes

Insurance Company #2*

Policy/Group #*

ID #*

Policy Holder's Name*

Policy Holder's Birth Date*

Policy Holder's Employer*

Medical History

Are you currently in good health?

Yes

No

Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)?

Yes

No

Which medications?

Do you currently smoke?

Yes

No

Are you allergic to or ever had a reaction to any of the following:

Penicillin

Codeine

Local Anesthetic (“freezing")

Aspirin (ASA)

Sulfa Drugs

Other

If Other, please specify:

Are you under the regular care of a physician?

Yes

No

Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal?

Yes

No

Have you ever had a serious illness or operation?

Yes

No

Do you currently have or ever had any of the following conditions?

Women: Are you pregnant?

Yes

No

Is there anything else we should know about your health?

Yes

No

If yes, please specify:

Dental History

What dental condition(s) concern you at present?

When was your last dental check-up and cleaning?

Were X-rays taken at your last dental visit?

Yes

No

When was the last time you changed dental offices?

Have you noticed any signs of the following?

Bleeding Gums

Drifting of Teeth

Gum Ache

Receding Gums

Loose Teeth

Do you have any clicking, popping or pain in your jaw joint?

Yes

No

Are you aware of clenching or grinding your teeth?

Yes

No

Do you have any missing teeth that you feel should be replaced?

Yes

No

Would you like to improve the appearance of your teeth?

Yes

No

Do you floss your teeth?

Yes

No

Have you had any complications or difficulty with previous dental treatment?

Yes

No

How do you rate yourself as a dental patient?

Calm

Slightly

Very Anxious

Confirmation

New Patients Welcome

Book Your Appointment Today

Whether you’re looking for a Calgary family dentist, a Calgary cosmetic dentist, or a Calgary emergency dentist, Panatella Dental is here to help. Contact us today to schedule your visit and experience dental care that’s professional, compassionate, and tailored to you.

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