(403) 225-1991
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(403) 225-1991
Why Choose Us
Dental Fees
Dental Insurance
FAQs
Health & Safety
Canyon and the Community
Services
Family Dentistry
Children’s Dentistry
Emergency Dentistry
Dental Hygiene & Teeth Cleanings
Root Canal Therapy
Orthodontics
Invisalign
6 Month Smiles
TMJ/TMD Therapy
Cosmetic Dentistry
Zoom Teeth Whitening
Porcelain Veneers
Cosmetic Tooth Bonding
Botox®
Restorative Dentistry
Dental Crowns
Dental Bridges
White Fillings
Oral Surgery
Tooth Extractions
Dental Implants
Wisdom Teeth Extractions
New Patients
New Patient Form
Team
Meet the Dentists
Dental Hygienists Team
Dental Assistant Team
Administration Team
Appointments
Education
Products
Contact
Book Now
Welcome to Canyon Dental Centre
"
*
" indicates required fields
Patient's Legal Name
*
Mr.
Mrs.
Ms.
They/Them
Prefix
First
Last
Prefer to be Called
Email
*
Date of Birth
*
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Sex
*
Male
Female
X Non-Binary
Transgender
Prefer Not To Say
Marital Status
*
Single
Married
Divorced
Widowed
Under Age 18
Prefer Not To Say
Cell Phone
*
Patient's Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Primary Insurance
Policyholder
Mr.
Mrs.
Ms.
They/Them
Prefix
First
Last
Insurance Company
Employer
Group/Policy Number
Identification/Certificate Number
Secondary Insurance
Policyholder
Mr.
Mrs.
Ms.
They/Them
Prefix
First
Last
Date of Birth
MM slash DD slash YYYY
Insurance Company
Employer
Group/Policy Number
Identification/Certificate Number
Referral Information
Who can we thank for referring you to our office?
EMERGENCY CONTACT INFORMATION
PERSON WE MAY CONTACT IN CASE OF AND EMERGENCY (OTHER THAN YOUR FAMILY HOME)
Name
*
Relationship
*
Cell Phone
*
Medical History
Doctor's Office Number
Name of physician
Most recent physical examination
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What is your estimate of your general health?
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
Hospitalization for illness or injury
*
Yes
No
Please add further details
An allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver)
latex
nuts
fruit
other
Please add further details
Heart problems, or cardiac stent within the last six months
*
Yes
No
Please add further details
History of infective endocarditis
*
Yes
No
Please add further details
Artificial heart valve, repaired heart defect (PFO)
*
Yes
No
Please add further details
Pacemaker or implantable defibrillator
*
Yes
No
Please add further details
Orthopedic implant (joint replacement)
*
Yes
No
Please add further details
Rheumatic or scarlet fever
*
Yes
No
Please add further details
High or low blood pressure
*
Yes
No
Please add further details
A stroke (taking blood thinners)
*
Yes
No
Please add further details
Anemia or other blood disorder
*
Yes
No
Please add further details
Prolonged bleeding due to a slight cut (INR > 3.5)
*
Yes
No
Please add further details
Pneumonia, emphysema, shortness of breath, sarcoidosis
*
Yes
No
Please add further details
Tuberculosis, measles, chicken pox
*
Yes
No
Please add further details
Asthma
*
Yes
No
Please add further details
Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
*
Yes
No
Please add further details
Kidney disease
*
Yes
No
Please add further details
Liver disease
*
Yes
No
Please add further details
Jaundice
*
Yes
No
Please add further details
Thyroid, parathyroid disease, or calcium deficiency
*
Yes
No
Please add further details
Hormone deficiency
*
Yes
No
Please add further details
High cholesterol or taking statin drugs
*
Yes
No
Please add further details
Diabetes
*
Yes
No
Please add further details
Type
HbA1c =
Stomach or duodenal ulcer
*
Yes
No
Please add further details
Digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
*
Yes
No
Please add further details
Osteoporosis/osteopenia (i.e. taking bisphosphonates)
*
Yes
No
Please add further details
Arthritis
*
Yes
No
Please add further details
Autoimmune disease
*
(i.e. rheumatoid arthritis, lupus, scleroderma)
Yes
No
Please add further details
Glaucoma
*
Yes
No
Please add further details
Contact lenses
*
Yes
No
Please add further details
Head or neck injuries
*
Yes
No
Please add further details
Epilepsy, convulsions
*
(seizures)
Yes
No
Please add further details
Neurologic disorders
*
(ADD/ADHD, prion disease)
Yes
No
Please add further details
Viral infections and cold sores
*
Yes
No
Please add further details
Any lumps or swelling in the mouth
*
Yes
No
Please add further details
Hives, skin rash, hay fever
*
Yes
No
Please add further details
STI/STD/HPV
*
Yes
No
Please add further details
Hepatitis
*
Yes
No
Please add further details
HIV/AIDS
*
Yes
No
Please add further details
Tumor, abnormal growth
*
Yes
No
Please add further details
Radiation therapy
*
Yes
No
Please add further details
Chemotherapy, immunosuppressive medication
*
Yes
No
Please add further details
Emotional difficulties
*
Yes
No
Please add further details
Psychiatric treatment
*
Yes
No
Please add further details
Antidepressant medication
*
Yes
No
Please add further details
Alcohol/recreational drug use
*
Yes
No
Please add further details
ARE YOU:
Presently being treated for any other illness
*
Yes
No
Please add further details
Aware of a change in your health in the last 24 hours
*
(i.e. fever, chills, new cough, or diarrhea)
Yes
No
Please add further details
Taking medication for weight management
*
Yes
No
Please add further details
Taking dietary supplements
*
Yes
No
Please add further details
Often exhausted or fatigued
*
Yes
No
Please add further details
Experiencing frequent headaches
*
Yes
No
Please add further details
A smoker, smoked previously or use smokeless tobacco
*
Yes
No
Please add further details
Considered a touchy/sensitive person
*
Yes
No
Please add further details
Often unhappy or depressed
*
Yes
No
Please add further details
Taking birth control pills
*
Yes
No
Please add further details
Currently pregnant
*
Yes
No
Please add further details
Diagnosed with a prostate disorder
*
Yes
No
Please add further details
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.
(i.e. Botox, Collagen Injections)
MEDICATION, SUPPLEMENTS, VITAMINS
List all medications, supplements, and or vitamins taken within the last two years.
Drug
Purpose
Add
Remove
Click the + icon on the right to add more rows.
Dental History
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
Previous Dentist
How long have you been a patient?
Date of most recent dental exam
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1932
1931
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1921
1920
Date of most recent x-rays
Month
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12
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Date of most recent treatment
Month
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12
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I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PERSONAL HISTORY
Are you fearful of dental treatment?
*
Yes
No
How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience?
*
Yes
No
Please add further details
Have you ever had complications from past dental treatment?
*
Yes
No
Please add further details
Have you ever had trouble getting numb or had any reactions to local anesthetic?
*
Yes
No
Please add further details
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
*
Yes
No
Please add further details
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
Yes
No
Please add further details
GUM AND BONE
Do your gums bleed or are they painful when brushing or flossing?
*
Yes
No
Please add further details
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
*
Yes
No
Please add further details
Have you ever noticed an unpleasant taste or odor in your mouth?
*
Yes
No
Please add further details
Is there anyone with a history of periodontal disease in your family?
*
Yes
No
Please add further details
Have you ever experienced gum recession?
*
Yes
No
Please add further details
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
*
Yes
No
Please add further details
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
*
Yes
No
Please add further details
TOOTH STRUCTURE
Have you had any cavities within the past 3 years?
*
Yes
No
Please add further details
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
*
Yes
No
Please add further details
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
*
Yes
No
Please add further details
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
*
Yes
No
Please add further details
Do you have grooves or notches on your teeth near the gum line?
*
Yes
No
Please add further details
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
Yes
No
Please add further details
Do you frequently get food caught between any teeth?
*
Yes
No
Please add further details
BITE AND JAW JOINT
Do you have problems with your jaw joint?
*
(pain, sounds, limited opening, locking, popping)
Yes
No
Please add further details
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
*
Yes
No
Please add further details
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
*
Yes
No
Please add further details
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
*
Yes
No
Please add further details
Are your teeth becoming more crooked, crowded, or overlapped?
*
Yes
No
Please add further details
Are your teeth developing spaces or becoming more loose?
*
Yes
No
Please add further details
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
*
Yes
No
Please add further details
Do you place your tongue between your teeth or close your teeth against your tongue?
*
Yes
No
Please add further details
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
Yes
No
Please add further details
Do you clench or grind your teeth together in the daytime or make them sore?
*
Yes
No
Please add further details
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
*
Yes
No
Please add further details
Do you wear or have you ever worn a bite appliance?
*
Yes
No
Please add further details
SMILE CHARACTERISTICS
Is there anything about the appearance of your teeth that you would like to change?
*
(shape, color, size)
Yes
No
Please add further details
Have you ever whitened (bleached) your teeth?
*
Yes
No
Please add further details
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
Yes
No
Please add further details
Have you been disappointed with the appearance of previous dental work?
*
Yes
No
Please add further details
ARE YOU INTERESTED IN OR HAVE YOU CONSIDERED
Select all that apply
Implants
Invisalign
Orthodontics
Cosmetic Dentistry
Nitrous Sedation
Whitening
Cosmetic Botox
Night Guard
X-Rays Release Form
I am requesting copy of my dental x-rays to be emailed to Canyon Dental Centre
*
Mr.
Mrs.
Ms.
They/Them
Prefix
Your First Name
Your Last Name
Cell Phone
*
Email
*
Name of previous dental office / Dentist :
*
Assignment & Release
*
I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claim, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively "My Images"), and (5) my dentist's use of My images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the "Uninsured Costs") in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment. If the above named Patient is a minor or unable to pay the Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient's dentist in accordance with the payment terms and policies (PLEASE SIGN).
*
28441
From all of us at Canyon Dental Centre, we look forward to seeing you soon.
Why Choose Us
Dental Fees
Dental Insurance
FAQs
Health & Safety
Canyon and the Community
Services
Family Dentistry
Children’s Dentistry
Emergency Dentistry
Dental Hygiene & Teeth Cleanings
Root Canal Therapy
Orthodontics
Invisalign
6 Month Smiles
TMJ/TMD Therapy
Cosmetic Dentistry
Zoom Teeth Whitening
Porcelain Veneers
Cosmetic Tooth Bonding
Botox®
Restorative Dentistry
Dental Crowns
Dental Bridges
White Fillings
Oral Surgery
Tooth Extractions
Dental Implants
Wisdom Teeth Extractions
New Patients
New Patient Form
Team
Meet the Dentists
Dental Hygienists Team
Dental Assistant Team
Administration Team
Appointments
Education
Products
Contact
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