Your SW Calgary Family & General Dentist

New Patient, Dental & Medical History Forms

    Welcome to Ultima Dental Wellness!
    Please kindly complete our Confidential Patient Information, Dental & Medical History Forms.


    PERSONAL INFORMATION


    INSURANCE INFORMATION

    Primary Insurance Information


    Secondary Insurance Information

    DENTAL HISTORY

    PLEASE CHECK TO ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS:

    PERSONAL HISTORY

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    GUM AND BONE

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    TOOTH STRUCTURE

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    Yes
    BITE AND JAW JOINT

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    SMILE CHARACTERISTICS

    CHECK IF YES

    Yes
    Yes
    Yes
    Yes

    MEDICAL HISTORY


    DO YOU HAVE or HAVE YOU EVER HAD:

    Yes
    Yes


    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes
    Yes

    Yes
    Yes

    Yes
    Yes

    ARE YOU:

    Yes

    Yes
    Yes
    Yes

    Yes
    Yes
    Yes

    Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Collagen Injections)

    Drug & Purpose 1

    Drug & Purpose 2

    Drug & Purpose 3

    Drug & Purpose 4

    PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.