Patient Registration

This is a secure form, your privacy is protected. Please complete the following information as best as possible and click on submit at the end. Alternatively, if you do not wish to use the online form submission. Please download the PDF form from the link to the right. If you have any questions about this form, do not hesitate to contact us directly at (587) 349-5858 before submitting the form.

Please fill out the information below as completely as possible.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to the Chestermere Station Periodontal Team.

Patient Information

Insurance Information
Do you have dental insurance?


Dual Plan

Health Information

Periodontal disease may be caused by a combination of several factors and the following questions are designed to help us identify them. The success of therapy is dependent upon this. Therefore, although some of the following questions may seem unrelated to your periodontal condition, they are all associated with proper management of your oral health.


All information is kept strictly confidential.


(example: aspirin, tranquilisers, steroids, etc.)*

Has your general health changed in the past year?Has your weight changed in the past year?Have you ever had any serious illness or major operations?Have you had abnormal bleeding associated with previous tooth extraction, surgery, or trauma?Do you heal slowly?Have you ever had any allergies? (food, dust, drugs, fur, latex, etc.)?

Dental anaesthetics (novocaine, etc.)AspirinPenicilin or other antibioticsCodeineBarbituates (sleeping pills)Other drugs

Do you consider yourself a nervous person?Have you ever been warned against taking any drug or medicine?Have you ever had an asthmatic attach?Are you ever short of breath or have chest pains after mild exertion?Do your ankles swell?Are you thirsty much of the time?Do you have a persistent cough or do you cough up blood?Do you consider yourself a nervous person?Have you ever had surgery or treatment for a tumour or growth of your head, mouth, or lips?

Dental History

For Women Only

Consent

Form Submission sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use prior to submitting your referral request.