New Patient? Save Time at Your First Visit

We’re so glad you’re here. Before your first visit, please complete your new patient paperwork online. It’s fast, secure, and saves you time when you come in.

Have questions? Call (587) 402-8160 or text us at (604) 239-1443.

St. Albert Braces Orthodontics New Patient Paperwork

"*" indicates required fields

Patient Biographical Information

Name*

First Last

Preferred Name (Optional)

Email*

Date of Birth*

Are you under 21 years old?*

Yes

No

Phone

Cell Phone*

Sex*

Male

Female

Preferred Pronouns:

Address*

Street Address Address Line 2 City Province Postal Code Country

How Did You Hear About Us?

Google

Social Media (Facebook/Instagram/etc)

Family/Friend

Live in the Area

Parent/Guardian Biographical Information

Relationship to Patient:*

Name*

First Last

Phone*

Date of Birth*

Email*

Does this Parent/Guardian and the Patient Share the Same Address?*

Yes

No

Address*

Street Address Address Line 2 City Province Postal Code Country

Would You Like to Add Another Parent/Guardian?*

Yes

No

Second Parent/Guardian Biographical Information

Relationship to Patient:*

Name*

First Last

Phone*

Date of Birth*

Email*

Does this Parent/Guardian and the Patient Share the Same Address?*

Yes

No

Address*

Street Address Address Line 2 City Province Postal Code Country

Dental History

Dentist Name:*

Last Routine Dental Checkup*

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Last Routine Dental Cleaning*

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Has the Patient Undergone an Orthodontic Consultation or Treatment Before?*

Yes

No

When was the Consult or Treatment?*

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

What is Your Main Orthodontic Concern?*

Medical History

Are you being treated for any medical condition at present or within the past two years?*

Yes

No

What is Your Condition?*

Have you been hospitalized in the past two years?*

Yes

No

When was Your Last Visit to a Physician?*

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Last Complete Physical Examination?*

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs including vitamins or naturopathic substances? Please list:

(Use the + Button to Add More)

Have you ever reacted adversely to any of the following?*

Please Indicate Any Medicine NOT Listed Above

Have you ever been advised against taking any specific type of medication?*

Yes

No

Allergies: do you have any of the following?

Please Indicate Any Allergic Conditions NOT Listed Above

Do any of these allergic conditions result in:

Can You Tell Us a Bit More?*

Have you been advised by your Medical Doctor or Dentist to take antibiotics prior to dental treatment?*

Yes

No

Do you bleed EXCESSIVELY from cut or injury, or bruise easily?*

Yes

No

Do you ankles, feet or hands swell?*

Yes

No

Are you thirsty much of the time or urinate more than 6 times per day?*

Yes

No

Has your weight, appetite or energy level changed dramatically recently?*

Yes

No

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?*

Yes

No

Have you tested HIV positive, or come in contact with the AIDS virus?*

Yes

No

Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?*

Yes

No

Have you ever had any injury or surgery to your face or jaws?*

Yes

No

Have you had any surgeries?*

Yes

No

Do you smoke or use any other forms of tobacco?*

Yes

No

Are you alcohol and/or drug dependent?*

Yes

No

Have you received treatment for your alcohol/drug dependency??*

Yes

No

Which of the Following Applies to You?

Is Your Cancer in Treatment or in Remission?*

Treatment

Remission

Please Indicate Any Disease, Condition or Problem NOT Listed Above

Is There a Family History of Any of the Above Conditions?*

Yes

No

Are You Pregnant (or Suspect You Would Be)?*

Yes

No

Is there anything else about your health we should be made aware of?

Do you wish to speak to the Doctor privately about any problem or medical condition?

Insurance

Do You Have Insurance?*

Yes

No

Are You the Policyholder?*

Yes

No

Policyholder Name*

First Last

Policyholder Date of Birth*

Please Upload Photos of the Front and Back of Your Insurance Card:*

Drop files here or

Max. file size: 40 MB.

We require your signature below to indicate your consent to perform the dental and oral procedures necessary for treatment, including the use of local anesthetic and/or relative analgesia as indicated, and that you assume responsibility for the fees associated with those procedures and finance charges if you fail to do so within adequate time

Name*

Date*