New Patient Form

How did you hear about us? (check)

Postcard
Yellow Pages
Smile Insider
Welcome Wagon
Website
Friend/Family Referral (name)
Walk By
Northern Edge Newsletter (community)

DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

Yes
No
Yes
No
Yes
No
Penicillin
Codeine
Local Anesthetic (“freezing")
Aspirin (ASA)
Sulfa Drugs
Yes
No
Yes
No
Yes
No
Heart Trouble or Stroke
Heart Murmur
Thyroid Disorder
Rheumatic Fever
Breathing Problems
Arthritis
HIV Positive
Tumors or Cancer
High/Low Blood Pressure
Hepatitis
Liver Disease
Kidney Disease
Mental Illness
Diabetes
Tuberculosis
Epilepsy or Seizure
Blood Disorders
Venereal Disease
Hormonal Disorder
Yes
No
Yes
No

DENTAL HISTORY

Yes
No
Bleeding Gums
Drifting of Teeth
Gum Ache
Receding Gums
Loose Teeth
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Calm
Slightly Nervous
Very Anxious

Confirmation

I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I will assume responsibility for fees associated with those procedures.

We proudly provide general, family, and cosmetic dental services to residents of the following neighborhoods of NW Calgary:

Address: 650, 1110 Panatella Blvd. NW
Calgary, AB, T3K 0S6
Corner of Panatella Blvd & Panatella Street NW
Phone: 403-226-4788
Fax: 403-226-4791

"This website is copyright J.A. THURMEIER PROFESSIONAL CORPORATION, Canada, 2010. Copying all or any portion of this website is strictly prohibited without the prior written consent of J.A. THURMEIER PROFESSIONAL CORPORATION. All rights reserved."

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