New Patient Form

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Crowns & Bridges

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Halitosis Treatment

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Dental Emergency

Root Canal Therapy

Wisdom Teeth Removal
General & Family Care

Tooth Extraction

TMJ & TMD Treatment

Cosmetic Dentistry

Gum Contouring

Porcelain Veneers

Teeth Whitening

Restoring Function

Tooth-Coloured Fillings

Crowns & Bridges

Dental Implants

Complete & Partial Dentures

Orthodontics

Invisalign
Children's Dentistry

Sedation Options

Fluoride Treatment

Dental Sealants

Space Maintainers

Gum Disease & Bad Breath

Periodontal Gum Care

Halitosis Treatment

Urgent Dental Care

Dental Emergency

Root Canal Therapy

Wisdom Teeth Removal
For Patients
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780 559 1111

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Emergency
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Home
About
- Meet The Team
- Our Office
- Why Us
- Blog
Emergency
Services
For Patients
Contact

New Patient Information 1/2:

Leave this field blank

Sex

Birth Date

Status

Child

Married

Single

Widowed

Divorced

Whom May We Thank For Your Referral

Google

Yellow Pages

News Paper

Flyer

Website

Other

Have you been under the care of a medical doctor during the past two years?

Yes

Are you aware of having an allergic (or adverse) reaction to any medication or substance?

Yes

Indicate which of the following you have had, or presently have: (optional)

Heart (Surgery, Disease, Attack)

Congenital Heart Disease

Glaucoma

Emphysema

Chronic Cough

Tuberculosis

Asthma

Cortisone Medicine

Swollen Ankles

Stroke

Are you taking blood thinners?

Artificial joints (hip, knee, etc.)

Latex Sensitivity

Heart Murmur

High Blood Pressure

H.I.V. Positive

Cold Sores/ Fever Blisters

Blood Transfusion

Arthritis/ Rheumatism

Allergies or Hives

Sinus Trouble

Radiation Therapy

Liver Disease

Nervous/ Anxious

Chest Pain

Thyroid Problems

A.I.D.S.

Hemophilia

Psychiatric/ Psychological Care

Kidney Trouble

Have you ever needed Premed. prior to dental treatment?

Bruise Easily

Neuroligical Disorders

Epilepsy or Seizures

Fainting or Dizzy Spells

Hepatitis

Stomach Ulcers

Venereal Disease

Artificial Heart Valve

Mitral Valve Prolapse

Heart Pacemaker

Rheumatic Fever

Sickle Cell Disease

Yellow Jaundice

Tumors

Chemotherapy

Do you smoke?

Diabetes

None of these options

Do you have, or have you had and medical conditions not listed?

Yes

·Women (optional)

Are you pregnant?

Yes

Are you nursing?

Yes

Are you taking birthcontrol?

Yes

What can we do to make YOU smile? Check all that apply.

Veneer/Crowns

Sedation Dentistry

Replace Metal fillings

Replace missing teeth

Correct misaligned teeth

Broken/Cracked Teeth

Dental Implants

TMJ/Night guard

Sports guards

Whitening

Whitening Are you apprehensive about dental treatment?

Yes

Do you have previous dental crowns?

Yes

Have you had problems with previous dental treatment?

Yes

Does the saliva in your mouth seem too much?

Yes

Do you gag easily?

Yes

Have you had orthodontic (braces) treatment?

Yes

Do you wear dentures?

Yes

Does food catch between your teeth?

Yes

Have you ever notice slow-healing sore in your mouth?

Yes

Do you have difficulty in chewing your food?

Yes

Do you experience pain when you chew?

Yes

Do you avoid brushing any part of your mouth because of pain?

Yes

Do you have temporomandibular jaw disorder (TMD)?

Yes

Are your teeth sensitive to cold?

Yes

Do you clench or grind your jaws frequently?

Yes

Are your teeth sensitive to heat?

Yes

Are you satisfied with the appearance of your teeth?

Yes

Are your teeth sensitive to sweeths?

Yes

Do you experience headaches or migraines?

Yes

Are your teeth sensitive ti sours?

Yes

Do you notice an unpleasant taste or odor in your mouth?

Yes

Do your gums bleed when you brush or floss?

Yes

Do you have sleep problems?

Yes

Do you have previous dental implants?

Yes

Treatment Consent

I, the under signed, authorize Royal Oak Smiles to perform any necessary dental services and oral surgery that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all dental services are my sole responsibility and that I should make myself aware of any fees associated with my dental care prior to treatment. Also, I, also acknowledge that there is no expressed, implied or guarantee of any procedure or dental treatment provided.

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