Intake

Personal details

Date of birth

Gender

Male

Female

Contact numbers

Address

In Case of Emergency

Insurance

Company

Policy / group number

Certificate / ID number

Name of policy holder

DOB of policy holder

If this is your first visit, how did you hear about our office?

Family/Friend

Community Flyer

Close to home/work

Internet

Dental History

1. When was your last visit?

3. Have you ever had complications associated with previous dental treatment?

Yes

4. Have you ever had a bad reaction to dental freezing?

Yes

5. Are you difficult to freeze?

Yes

6. Have you been advised by your family doctor to take antibiotics (pre-medication) before dental treatment?

Yes

7. Are you nervous about dental treatment?

Yes

8. Are you aware of clenching or grinding your teeth?

Yes

9. Do you wear a night guard appliance?

Yes

10. Do you feel uncomfortable or self-conscious about the appearance of your teeth?

Yes

11. Are you interested in cosmetic dentistry?

Veneers

Teeth Whitening

Invisible Braces

Other

Disclosure

The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance on my account. I also authorize Beacon Hill Dental or insurance company to release any information required to process my claims. I understand that my account will be charged $50.00 per hour for any missed appointments or appointments cancelled with less than 2 business days notice.

I have read and agree that the information above is correct

Medical History

Please answer the following questions to the best of your ability. This information is confidential.

1. Are you currently being treated by a doctor?

Yes

2. Have you ever been hospitalized or had a major operation?

Yes

3. Have you ever had a serious head or neck injury?

Yes

4. Are you taking any medications, vitamins, or recreational drugs?

Yes

5. Do you smoke, vape or use chewing tobacco?

Yes

6. Are you taking any medications for osteoporosis or breast cancer?

Yes

8. Do you have any medical conditions not listed above?

Yes

10. Are you allergic to any other medication(s) not listed above?

Yes

11. Are you pregnant or nursing?

Yes

Disclosure

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform Beacon Hill Dental of any changes in medical status. I consent to the performing of the dental and oral procedures agreed to be necessary or advisable, including the use of general anesthetic or local anesthetic or any drugs as indicated.

Please review your dental plan very carefully to ensure you understand the exclusions and limitations of your plan. If your dental plan does not cover the full cost of treatment, you will be responsible for any difference between the amount paid by your dental plan and the amount charged for your treatment.

I have read and agree that the information above is correct

We proudly accept the Canadian Dental Care Plan (CDCP)
Making dental care more accessible for eligible Canadians

We are pleased to announce that Beacon Hill Dental follows the new 2025 Alberta Dental Fee Guide. Read more.