Dental New Patient Forms

Janz Family Dental, located in West Edmonton, has served the community with general and cosmetic dentistry since 1993. Our clinic welcomes new patients, and we request you visit the Meet Our Dentists page to familiarize yourself with our team. You can schedule an appointment with a phone call. Please fill out our medical and dental history questionnaire. We hope to see you soon!

Medical & Dental History

FIRST NAME*

Last NAME*

DATE OF BIRTH

STREET ADDRESS

CITY

PROVINCE

POSTAL CODE

HOME PHONE*

CELLULAR PHONE

BUSINESS PHONE

EMAIL*

HOW DID YOU HEAR ABOUT US?

DO YOU HAVE DENTAL INSURANCE?

YES

PRIMARY INSURANCE NAME

PRIMARY INSURANCE POLICY #

PRIMARY INSURANCE CERTIFICATE #

SECONDARY INSURANCE NAME

SECONDARY INSURANCE POLICY #

SECONDARY INSURANCE CERTIFICATE #

MEDICAL HISTORY: THE FOLLOWING INFORMATION IS REQUIRED TO ENABLE US TO PROVIDE YOU WITH THE BEST POSSIBLE DENTAL CARE. ALL INFORMATION IS STRICTLY PRIVATE AND IS PROTECTED. PLEASE FILL IN THE ENTIRE FORM.

1. ARE YOU BEING TREATED FOR ANY MEDICAL CONDITION AT THE PRESENT OR HAVE BEEN TREATED WITHIN THE PAST YEAR? IF SO, WHAT WAS THE TREATMENT RENDERED. PLEASE WRITE A BRIEF DESCRIPTION:

2. WHEN WAS YOUR LAST MEDICAL CHECKUP?

3. HAS THERE BEEN ANY CHANGE IN YOUR GENERAL HEALTH IN THE PAST YEAR? IF YES, PLEASE EXPLAIN.

4. ARE YOU TAKING ANY MEDICATIONS, NON-PRESCRIPTION DRUGS, NATURAL SUPPLEMENTS OF ANY KIND? IF YES, PLEASE LIST WITH DOSES OR PROVIDE LIST.

5. DO YOU HAVE ANY ALLERGIES? IF YES, PLEASE LIST BELOW

YES

A) TO MEDICATIONS:

B) TO LATEX / RUBBER PRODUCTS / METALS:

C) OTHER (IE. HAY FEVER, FOODS, DYES):