Confidential Patient Record
Patient: Mr. / Mrs. / Miss______________________________________________________________________________________
Date of Birth: ________________________ Emergency Contact Name: __________________ Phone #:____________________
Address: _______________________________________________________ Marital Status: Married Single
Postal Code: __________________ Email:
Work #: ____________________ Cell #: ___________________________
Occupation: ________________________ Employer: ______________________
Friend/Family Referral (name) ______________________________________
Do you have Dental Insurance Coverage? Yes No
If yes, please provide us with benefits card for direct bil ing
1. Are you currently in good health? Yes
2. Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)? Yes
If yes, please list_______________________________________________________________________________________
4. Are you allergic to or ever had a reaction to any of the following: (please circle)
5. Are you under the regular care of a physician
If yes, Please explain ___________________________________________________________________________________
6. Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal? Yes No 7. Have you ever had a serious il ness or operation?
8. Do you currently have or ever had any of the fol owing conditions? (please circle)
No If yes, which trimester? ______________________________________
9. Is there anything else we should know about your health? Yes No If so, please explain__________________________
1. What dental condition(s) concern you at present? _________________________________________________________
2. When was your last dental check-up and cleaning? _________________________________________________________ 3. Were X-rays taken at your last dental visit?
4. When was the last time you changed Dental Offices _________________________________________________________
Have you noticed any signs of the fol owing? (please circle)
Bleeding gums Swel ing of Gums Gum Ache Receding Gums Loose Teeth Drifting of Teeth
6. Do you have any clicking, popping or pain in your jaw joint?
7. Are you aware of clenching or grinding your teeth?
8. Do you have any missing teeth that you feel should be replaced?
9. Would you like to improve the appearance of your teeth?
11. Have you had any complications or difficulty with previous dental treatment?
12. How do you rate yourself as a dental patient?
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 wil assume responsibility for fees associated with those procedures.
Copperstone Dental complies with the Alberta Personal Information Act (PIPA) and the Health Professions Act in
regards to the management, col ection, destruction, use and disclosure of our patient’s personal dental/medical
Cancel ation Policy
Due to a continuous high demand in prime appointment times, we require a minimum of 2 business days
notice should you require to reschedule your appointment. This is valuable time that the Doctor and staff have
reserved specifical y for you. In the case that insufficient notice is given or you fail to attend your appointment on
multiple occasions, we wil not be able to schedule and reserve future appointment times for you.
Due to the Canadian Personal Privacy Act, we are unable to access any sufficient information from your insurance
company regarding your dental plan. It is your responsibility
to know the details involved in your plan such as
annual maximums, frequencies, and any other limitations. We extend the courtesy to bil your insurance
however to avoid any patient portion discrepancies, please be ful y aware of the particulars of your plan so you can
utilize your benefits to their maximum. Copperstone Dental
can also provide estimates when requested so you
is pleased to offer you the fol owing payment options. Please CIRCLE
which option you would
Payment is due in full the day of treatment is rendered. We accept Cash, Visa, Debit, MasterCard,
and American Express. Copperstone Dental
wil process your payment on the date treatment is
rendered. Our treatment coordinator wil assist you in submitting the necessary documents to
your insurance carrier and the insurance cheque wil be sent directly to you, the patient.
You wil be required to leave your credit card number on file and we wil direct bil your insurance
company. Any outstanding amounts wil be applied to your credit card on file once your
insurance company has paid us their portion.
If we receive an explanation of covered costs from your insurance company at the time of your visit, you wil be
required to pay the outstanding balance before you leave.
Please sign below acknowledging that you have read and understand the office polices at Copperstone Dental
For Option B only:
I, _________________________________________ have chosen Option Two,
and herby authorize
any balances outstanding which is not covered by my dental insurance to be automatical y applied to:
Credit Card (circle one):
Card Number: ________-________-________-________ Expiry Date :____________( mm/yyyy)
Name (as it appears on card)
Signature of Cardholder:________________________________________
Receipts wil be emailed to the fol owing address:
Personal Information Instructions Please fill out this form as completely as you can. Print your answers . Today's Date Marital Status First Name Ethnicity Last Name Gender [ ] Male [ ] Female Date of Birth Occupation Address and Please give your home address. Please indicate by circling the appropriate letter whether I can leave a fu
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