Pay Online

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

HOME
OUR DIFFERENCE
PROCEDURES
New Patient Information
Blog
CONTACT US

REQUEST APPOINTMENT

Pay Online

New Patient Information form

Step 1/2:

Leave this field blank

Name

Phone

Sex

Birth Date

Emergency

Phone

Status

Child

Married

Single

Widowed

Divorced

Whom May We Thank For Your Referral

Google

Yellow Pages

News Paper

Flyer

Website

Other

Have you been under the care of a medical doctor during the past two years?

Yes

Are you aware of having an allergic (or adverse) reaction to any medication or substance?

Yes

Indicate which of the following you have had, or presently have: (optional)

Heart (Surgery, Disease, Attack)

Congenital Heart Disease

Glaucoma

Emphysema

Chronic Cough

Tuberculosis

Asthma

Cortisone Medicine

Swollen Ankles

Stroke

Are you taking blood thinners?

Artificial joints (hip, knee, etc.)

Latex Sensitivity

Heart Murmur

High Blood Pressure

H.I.V. Positive

Cold Sores/ Fever Blisters

Blood Transfusion

Arthritis/ Rheumatism

Allergies or Hives

Sinus Trouble

Radiation Therapy

Liver Disease

Nervous/ Anxious

Chest Pain

Thyroid Problems

A.I.D.S.

Hemophilia

Psychiatric/ Psychological Care

Kidney Trouble

Have you ever needed Premed. prior to dental treatment?

Bruise Easily

Neuroligical Disorders

Epilepsy or Seizures

Fainting or Dizzy Spells

Hepatitis

Stomach Ulcers

Venereal Disease

Artificial Heart Valve

Mitral Valve Prolapse

Heart Pacemaker

Rheumatic Fever

Sickle Cell Disease

Yellow Jaundice

Tumors

Chemotherapy

Do you smoke?

Diabetes

None of these options

Do you have, or have you had and medical conditions not listed?

Yes

Are you pregnant?

Yes

Are you nursing?

Yes

Are you taking birthcontrol?

Yes

What can we do to make YOU smile? Check all that apply.

Veneer/Crowns

Sedation Dentistry

Replace Metal fillings

Replace missing teeth

Correct misaligned teeth

Broken/Cracked Teeth

Dental Implants

TMJ/Night guard

Sports guards

Whitening

Whitening Are you apprehensive about dental treatment?

Yes

Do you have previous dental crowns?

Yes

Have you had problems with previous dental treatment?

Yes

Does the saliva in your mouth seem too much?

Yes

Do you gag easily?

Yes

Have you had orthodontic (braces) treatment?

Yes

Do you wear dentures?

Yes

Does food catch between your teeth?

Yes

Have you ever notice slow-healing sore in your mouth?

Yes

Do you have difficulty in chewing your food?

Yes

Do you experience pain when you chew?

Yes

Do you avoid brushing any part of your mouth because of pain?

Yes

Do you have temporomandibular jaw disorder (TMD)?

Yes

Are your teeth sensitive to cold?

Yes

Do you clench or grind your jaws frequently?

Yes

Are your teeth sensitive to heat?

Yes

Are you satisfied with the appearance of your teeth?

Yes

Are your teeth sensitive to sweeths?

Yes

Do you experience headaches or migraines?

Yes

Are your teeth sensitive ti sours?

Yes

Do you notice an unpleasant taste or odor in your mouth?

Yes

Do your gums bleed when you brush or floss?

Yes

Do you have sleep problems?

Yes

Do you have previous dental implants?

Yes

Treatment Consent

I, the under signed, authorize Royal Oak Smiles to perform any necessary dental services and oral surgery that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all dental services are my sole responsibility and that I should make myself aware of any fees associated with my dental care prior to treatment. Also, I, also acknowledge that there is no expressed, implied or guarantee of any procedure or dental treatment provided.

Signature

FullName2 (optional)

Get In Touch!

Leave this field blank

For all your dental care needs, feel free to reach out to Sierra Springs Dental at (403) 945-4555 or visit our office at 2821 Main Street South #103 Airdrie, AB T4B 3S6. Your smile is our priority

FullName2 (optional)

Contact Info

(403) 945-4555

2821 Main Street South #103
Airdrie, AB T4B 3S6

REQUEST APPOINTMENT

Pay Online

Office Hours

Mon-Thu: 8:00 AM to 8:00 PM
Fri-Sat: 8:00 AM to 4:00 PM
Sun: 9:00 AM to 4:00 PM

Get In Touch!

Leave this field blank

For all your dental care needs, feel free to reach out to Sierra Springs Dental at (403) 945-4555 or visit our office at 2821 Main Street South #103 Airdrie, AB T4B 3S6. Your smile is our priority

FullName2 (optional)

Contact Info

(403) 945-4555

2821 Main Street South #103
Airdrie, AB T4B 3S6

REQUEST APPOINTMENT

Pay Online

Office Hours

Mon-Thu: 8:00 AM to 8:00 PM
Fri-Sat: 8:00 AM to 4:00 PM
Sun: 9:00 AM to 4:00 PM

Website Design by:

Ask Questions

Leave this field blank

Name

Phone

Message

FullName2 (optional)

Request an appointment

Leave this field blank

Name

Phone

Reason for visit:

FullName2 (optional)