P A T I E N TPatient First Name:
M.I.
Patient Last Name:
Sex: male
female Date of Birth
(M/D/Y): Age:
Alberta Healthcare#:
Street:
City Province:
Postal Code
Home Tel: Bus.
Tel: Ext.
Dentist:
Orthodontist:
Other Dental Specialist:
Physician:
Referred By:
Have you ever been a patient in our practice: Yes
No
Method of Personal Payment: Cash Check Credit Card
A C C O U N T
Who will be responsible for your account? Self
Spouse
Father
Mother
Other
Name:
Alberta Healthcare#:
Home Tel: Street:
City State: Zip
Employer: Tel:
PRIMARY DENTAL INSURANCE
Employer:
Address:
Bus. Tel:
Insurance Company Name:
Address:
Phone:
Group No.: Group Name:
Insured Party: Relation:
Sex: MF
Date of Birth (MM/DD/YY):
Street: City:
Province:
Postal Code:
Phone:
Alberta Healthcare#:
ID No.:
SECONDARY DENTAL INSURANCE
Employer:
Address:
Bus. Tel:
Insurance Company Name:
Address:
Phone:
Group No.: Group Name:
Insured Party: Relation:
Sex: MF
Date of Birth (MM/DD/YY):
Street: City:
Province:
Postal Code:
Phone:
Alberta Healthcare#:
ID No.:
Please fill out the health history to the best of your knowledge
All patient information is confidential
Although oral surgeons primarily treat the area in and around
your mouth, your mouth is a part of your entire body. Health
problems that you may have or medication that you may be taking,
could have an important interrelationship with the care that you
will be receiving. Thank you for answering the following questions.
Your answers are for our records only and will be considered
confidential.
Reason for your visit:
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