New Client Form Saskatoon dental care for the entire family. Book an Appointment New Patient FormΔFirst Name Last Name Birthday (Day/Month/Year) Gender MaleFemaleAddressAddress Line 1 Address Line 2 City Province Postal Code Home Phone Work Phone Would you like to receive appointment confirmation by email? Yes NoEmail Emergency Contact Name Emergency Contact Phone Physician Physician Phone # Health Card # How did you hear about us? Text Input Insurance InfoCompany Policy # ID # Insurance Info- If you have a another insurance providerCompany Policy # ID # Medical Information- List all the drugs (prescription, non prescription, herbal) that you are presently taking or have taken recently: Do you have any allergies? (Please list) Do you smoke or use chewing tobacco? Yes NoDo you have or have you had any of the following? Heart attack Stroke HIV or AIDS Stomach Ulcers Arthritis Heart failure Angina Chronic Bronchitis Organ transplant Cancer Artificial joints epilepsy/seizures under or over active thyroid Asthma pacemaker Fainting spells Tuberculosis Hepatitis Rheumatic fever Psychiatric disorder Liver impairment Heart murmur Irregular heartbeat High blood pressure Emphysema Diabetes Heart defect Artificial heart valve Bleeding disorder Blood thinners Bisphosphonate use for osteoporosisList any disability, condition or problem not listed above: Are you pregnant or nursing? Yes NoWhat is your main concern about your mouth? Are you nervous about dental treatment? Yes NoDo you have or have you had any of the following? dental implants bleeding gums loose teeth injured teeth sensitive teeth uncomfortable jaw jaw joint noises jaw locking tooth extractions clenching/grinding tooth whitening gum surgery dentures orthodontic braces or appliances oral piercing root canal therapy crowns or bridges TMJ treatmentWhen was your last complete exam by a dentist? When was your last complete exam by a hygienist? Submit Form
(306) 665-6665
