Medical and Dental History Form

We Accept New Patients at Janz Family Dental

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


Fill out the form given below or download the form.


MEDICAL AND DENTAL HISTORy

Home Address

Yes
No

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.

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Chest pain
angina
rheumatic fever
lung disease
stomach ulcers
Drug/alcohol dependency
Heart attack
tuberculosis
arthritis
osteoporosis medications
stroke
cancer
seizure(epilepsy)
shortness of breath
heart murmur
steroid therapy
kidney disease
pace maker
diabetes
thyroid disease
organ transplant
malignant hypothermia
mental health disorder
Yes
No
Yes
No

FOR WOMEN ONLY:

Yes
No
Yes
No

DENTAL HISTORY

Good
Fair
Poor
Bleeding Gums
Crooked Teeth
Cosmetic
Loose Teeth
Bad Breath
Food Trapping
Sensitive Teeth
Toothache
Loose Dentures
Missing Teeth/Spaces
Want Whiter Teeth

PATIENT CERTIFICATION AND CONSENT

I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. Unless other arrangements are made payment is due at each office visit. Unpaid accounts may be subject to interest. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and the dentist. I authorize the dentist to treat me and I assume full responsibility of the fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.

LOCATION

10470 Mayfield Rd NW, Mayfield Square

Edmonton Alberta

Canada, T5P 4P4

PHONE: 780-484-8573

HOURS

Monday 08:00 AM - 06:00 PM

Tuesday 08:00 AM - 08:00 PM

Wednesday 08:00 AM - 06:00 PM

Thursday 08:00 AM - 08:00 PM

Friday - Saturday 08:00 AM - 04:00 PM

Closed on all holidays

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