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Patient Information

To assist us in serving you, please complete the following confidential form. The information provided is important to your dental health.

Feel free to download our Patient Information Form instead if you wish to fill it out offline.

Step 1 of 3

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Name
Prefix First Last Suffix
Preferred Name
First Last
Birthdate
If a Minor, Parents Names
Home Phone
Work Phone
Mobile Phone
Your Email
Address
Street Address Address Line 2 City Province Postal Code
What's Your Relationship Status?
Marital Status
- Single
- Common-Law
- Married
Common-Law/Spouse's Name
First Last
Common-Law/Spouse's Employer
Emergency Contact Info
Energency Contact
First Last
Emergnecy Contact Number
Relationship
Employer Info
Company Name
Employer Name
First Last
Your Occupation
How May we Contact You?
Do you agree to receive appointment reminders by text and/or email?
- Yes
Credit Where Credit is Due!
Whom may we thank for referring you to our office?
- Friend
- Facebook
- Postcard
- Google
- Other

Primary Insurance
Policy Holders Name
First Last
Policy Holders DOB
Policy Holders Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dental Insurance Company
Group Number
ID Number
Do You Have Secondary Insurance?
- First Choice
Secondary Insurance
Policy Holders Name2
First Last
Policy Holders DOB2
Policy Holders Address2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Group Number2
Dental Insurance Company2
ID Number2

Medical Health History
Do you have or have you had any of the following? (Please check any that apply)
- Abnormal bleeding after extractions, surgery, or trauma
- AIDS or HIV positive
- Alcoholism
- Anemia or blood disorder
- Anemia or blood disorders
- Arthitis
- Artificial joing orvalve heart aliment or angina
- Asthma Cancer or Tumor
- Diabetes
- Emothoinal condiiton
- Epilepsy, seizures, or fainting spells
- Hayfever, or sinus trouble
- Heart murmur, mitral value prolapse, heart defect
- Hepatitis or oter liver disease
- Herpes or cold sores
- High or low blood pressure
- Kidney disease
- Migraine headaches or frequent headaches
- Neurologic condition
- Pacemaker
- Rheumatic fever or rheumatic heart disease
- Tuberculosis or other lung problems
Are you taking any of the following?
- Antibiotics or sulfa drugs
- Anticoagulants (blood thinners)
- Antidepressants or tranquilizers
- Aspirin
- Cortisone or other steroids
- High blood pressure medicine
- Insulin, Orinase, or other diabetes drug
- Nitroglycerin
- Osteoporosis (bone density) medicine
- Other
Other
Women
- Taking hormones or contraceptives
- May be pregnant
Expected Delivery Date
Name of Your Physician
First Last
Do you have any diseases, condiiton, or problem not listed above?
Please add anything else you would like us to know about.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status
Comments
This field is for validation purposes and should be left unchanged.

Location

Southwest Smiles Dental Clinic
1113 Windermere Way,
Edmonton, Alberta, T6W 2P3, Canada
Phone: +1 587.773.9292
Fax: +1 587.773.9293
Email: info@southwestsmiles.ca

Hours of Operation

Monday: 8am to 8pm
Tuesday: 8am to 8pm
Wednesday: 8am to 8pm
Thursday: 8am to 8pm
Friday: 8am to 3:30pm
Saturday: 8am to 12pm
Sunday: 10am to 6pm

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Dental Practice
Dental Team
Services
Technology
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Patient Portal
Contact

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Patient Portal
Contact

Creating beautiful smiles for life.