Patient Form

403-932-9889

info@bowriverdental.ca

#104, 30 Bow Street Common, Cochrane

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Cochrane
Dental Services

Our patients and their families are a cherished part of our community and we welcome new patients! We do not require referrals from previous practitioners.

Conveniently located at the corner of Bow Street and Centre Avenue, we are right next door to Good Earth Coffeehouse.

Your First Visit

Giving Back to Cochrane

Canadian Dental Care Plan

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New patient form

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New patient form
Bow River Dental centre

Personal Information

Name

First

Last

Email

Date of Birth

Gender

MaleFemale

Marital Status

SingleMarriedChildOther

Address

Street Address

Street Address 2

City

Province

Postal Code

Cell Phone

Home Phone

Family Physician

Phone

Emergency Contact Name

Emergency Contact Number

Occupation

Whom may we thank for your referral to our office?

Insurance Information

Name of Insured

Date of Birth

Employer

Name of Insurance Co:

Policy#

ID#

Div#

Name of Insured

Date of Birth

Employer

Name of Insurance Co:

Policy#

ID#

Div#

Signature

Print Patient Name

Date

Signature Name

Thank you! Your submission has been received!

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Medical history form

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Medical history form
Bow River Dental centre

Patient Information

Name

First

Last

Age

Please enter a number from 1 to 110.

Phone

Email

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?

ExcellentGoodFairPoor

DO YOU HAVE OR HAVE YOU EVER HAD:

1. hospitalization for illness or injury

YesNo

2. an allergic or bad reaction to any of the following:

YesNo

Allergic Items:

aspirin, ibuprofen, acetaminophen, codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

chlorhexidine (CHX)

metals (nickel, gold, silver)

latex

nuts

fruit

milk

reddye

hives

skin rash

hay fever

other

3. heart problems, or cardiac stent within the last six months

YesNo

4. history of infective endocarditis

YesNo

5. artificial heart valve, repaired heart defect (PFO)

YesNo

6. pacemaker or implantable defibrillator

YesNo

7. joint replacement or heart valve replacement

YesNo

8. heart murmur, rheumatic or scarlet fever

YesNo

9. high blood pressure

YesNo

10. low blood pressure

YesNo

11. stroke (taking blood thinners)

YesNo

12. anemia or other blood disorder

YesNo

13. prolonged bleeding due toa slight cut (or INR greater than 3.5)

YesNo

14. pneumonia, emphysema, shortness of breath, sarcoidosis

YesNo

15. chronic ear infections, tuberculosis, measles, chicken pox

YesNo

16. breathing problems (e.g. asthma, stuffy nose, sinus congestion)

YesNo

17. sleep problems (e.g. sleep apnea, snoring, insomnia or restless sleep)

YesNo

18. kidney disease

YesNo

19. liver disease or jaundice

YesNo

20. vertigo (e.g. ”the room is spinning”)

YesNo

21. thyroid, parathyroid disease, or calcium deficiency

YesNo

22. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)

YesNo

23. high cholesterol or taking statin drugs

YesNo

24. diabetes

YesNo

25. stomach or duodenal ulcer or digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)

YesNo

26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)

YesNo

27. arthritis or gout

YesNo

28. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)

YesNo

31. epilepsy, convulsions (seizures)

YesNo

32. neurologic disorders (ADD/ADHD, prion disease)

YesNo

33. viral infections and cold sores

YesNo

34. any lumps or swelling in the mouth

YesNo

35. hives, skin rash, hay fever

YesNo

36. hepatitis

YesNo

37. HIV/AIDS

YesNo

38. tumor, abnormal growth

YesNo

39. radiation therapy

YesNo

41. medication treatment or antidepressant medication (Autism, Sensory Issues, ADHD)

YesNo

42. recreational drug use

YesNo

Are You:

43. presently being treated for any other illness

YesNo

44. experiencing frequent headaches or chronic pain

YesNo

45. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)

YesNo

46. currently pregnant

YesNo

47. diagnosed with a prostate disorder

YesNo

Additional Information

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

List all medications, supplements, and or vitamins taken within the last two years

Drug & Purpose 1

Drug & Purpose 2

Drug & Purpose 3

Drug & Purpose 4

Signature

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

Print Patient or Patient's Authorized representative

Date

Signature Name

Relationship of status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)

Thank you! Your submission has been received!

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Dental History form

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Dental History form
Bow River Dental centre

Patient Information

Name

First

Last

Email

Date of Birth

Referred by

How would you rate the condition of your mouth?

ExcellentGoodFairPoor

Previous Dentist

How long have you been a patient? (Months/Years)

Date of most recent dental exam

Date of most recent x-rays

Date of most recent treatment (other than a cleaning)

I routinely see my dentist every

3 Months6 Months12 MonthsNot routinely

Name of Physician/and their specialty

Please answer YES or NO to the following questions:

Personal History

1. Are you fearful of dental treatment?

YesNo

2. Have you had an unfavorable dental experience?

YesNo

3. Have you ever had complications from past dental treatment?

YesNo

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

YesNo

5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

YesNo

6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

YesNo

GUM AND BONE

7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?

YesNo

8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

YesNo

9. Have you ever noticed an unpleasant taste or odor in your mouth?

YesNo

10. Is there anyone with a history of periodontal disease in your family?

YesNo

11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?

YesNo

12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

YesNo

13. Have you experienced a burning or painful sensation in your mouth not related toyour teeth?

YesNo

TOOTH STRUCTURE

14. Have you had any cavities within the past 3 years?

YesNo

15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

YesNo

16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

YesNo

17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

YesNo

18. Do you have grooves or notches on your teeth near the gum line?

YesNo

19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

YesNo

20. Do you frequently get food caught between any teeth?

YesNo

BITE AND JAW JOINT

21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

YesNo

22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

YesNo

23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

YesNo

24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

YesNo

25. Are your teeth becoming more crooked, crowded, or overlapped?

YesNo

26. Are your teeth developing spaces or becoming more loose?

YesNo

27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

YesNo

28. Do you place your tongue between your teeth or close your teeth against your tongue?

YesNo

29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

YesNo

30. Do you clench or grind your teeth together in the daytime or make them sore?

YesNo

31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

YesNo

32. Do you wear or have you ever worn a bite appliance?

YesNo

SMILE CHARACTERISTICS

33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change(shape, color, size, display)?

YesNo

34. Have you ever whitened (bleached) your teeth?

YesNo

35. Have you felt uncomfortable or self-conscious about the appearance of your teeth?

YesNo

36. Have you been disappointed with the appearance of previous dental work?

YesNo

Signature

Signature Name

Thank you! Your submission has been received!

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X-ray release form

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X-ray release form
Bow River Dental centre

Personal Information

Patient Name

First

Last

Email

Gender

MaleFemale

Date of Birth

I request and authorize Dr.

Phone

To release health care information of the patient name above, to:

Bow River Dental Centre

Address: #104, 30 Bow Street Common,

Cochrane, Alberta, T4C 2N1

Phone: 403-932-9889

This request and authorization apply to:

Copy of complete dental chart including periodontal measurements
Copy of dental x-rays (including Panoramic or FMS)

I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

Please note, the Supreme Court of Canada has ruled:

“A patient is entitled to copies of their dental records provided a signed authorization is received….”

Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.

Signature

Print Patient or Patient's Authorized representative

Date

Signature Name

Relationship of status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)

Thank you! Your submission has been received!

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Experience the warmth of a family-owned dental practice, committed to treating you like one of our own. Our motto at Bow River Dental Centre is “We treat everyone like family!”

Office Hours

Monday: 8am – 7:00pm

Tuesday:8am – 8:00pm

Wednesday:8am – 8:00pm

Thursday:8am – 4:30pm

Friday: 8am – 4:30pm

Saturday:9am – 3:00pm*

*By appointments only.

Office Information

#104, 30 Bow Street Common,
Cochrane, Alberta, T4C 2N1

info@bowriverdental.ca

© All rights reserved for ⦁ Bow River Dental Centre

Book Your
Appointment Today

We Treat Everyone Like Family

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