New Patients

New Patients Info

At Appleway Dental Clinics, we are always excited to meet new patients from Red Deer and surrounding areas. Our team will work with you to develop a comprehensive treatment plan to help you achieve the healthy, beautiful smile you have always wanted. If you’re planning to visit us for any dental treatment, schedule an appointment today.

 

Want to help lower your wait time? Please fill out our New Patient form below.

Medical and Dental History

PERSONAL INFORMATION

Address

Contact Information

Insurance Information (Primary & Secondary)

DENTAL HISTORY

PERSONAL HISTORY

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Smile Characteristics

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Bite and Jaw Joint

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Tooth Structure

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Gum and Bone

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MEDICAL HISTORY

Do you have OR have you ever had:

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No
Aspirin, ibuprofen, acetaminophen , codeine
Penicillin
Erythromycin
Tetracycline
Sulpha
Local anesthetic
Fluoride
Metals, (nickel, gold, silver, ________)
Latex
Other
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
No
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B
C
D
E
Yes
No
Yes
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Yes
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Yes
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Yes
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Yes
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Yes
No

Are you:

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No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Option 1
Yes
No
Yes
No
Yes
No

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

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