Our Dentists are Accepting New Patients in Calgary NW

You can get a head start on your appointment with Dentrix Dental Care, serving northwest Calgary, by filling out our new patient form on this page. Both of our locations have Dentists that are accepting new patients.

Alternatively, you can download and print the New Patient form for Dentrix – North Hill. If you have any questions about the form, or about our services, just contact us.

New Patient Form

*mandatory fields
Preferred Clinic Location
Gender
First Name*
Middle Name
Last Name*
Preffered Name*
Marital Status*
Birth Date*
Street Address*
Apartment #
City*
Province*
Postal code*
Email address*
Home Phone*
Work Phone
Other Phone
Preferred Appointment Time
Preferred time
- Morning
- Afternoon
- Evening
- Anytime
Preferred day of the week
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Health Information
Date of last dental visit*
Have you ever had any of the following? Please check those that apply.
Allergies
- Yes
- No
Type of allergy
Latex allergy
- Yes
- No
Drug Allergies
Aspirin allergy
- Yes
- No
Codeine allergy
- Yes
- No
Penicillin allergy
- Yes
- No
Sulpha allergy
- Yes
- No
Artificial joints
- Yes
- No
Location of artificial joints
Date of surgery
Asthma
- Yes
- No
Asthma medications
Blood disease
- Yes
- No
Cancer
- Yes
- No
Diabetes
- Yes
- No
Epilepsy
- Yes
- No
Excessive bleeding
- Yes
- No
Fainting
- Yes
- No
Heart disease
- Yes
- No
Hepatitis
- Yes
- No
High blood pressure
- Yes
- No
HIV
- Yes
- No
Kidney disease
- Yes
- No
Liver disease
- Yes
- No
Low blood pressure
- Yes
- No
Nervous disorders
- Yes
- No
Pacemaker
- Yes
- No
Pregnant - due date
Birth control medication name
Radiation treatment
- Yes
- No
Respiratory problems
- Yes
- No
Rheumatic fever
- Yes
- No
Stroke
- Yes
- No
Osteoporosis
- Yes
- No
Other medications
Have you ever had any complications following dental treatment?
- Yes
- No
If yes, please explain
Have you been admitted to a hospital or needed emergency care during the past two years?
- Yes
- No
If yes, please explain
Are you now under the care of a physician for medical treatment?
- Yes
- No
If yes, please explain
Name of physician
Physician's phone
Do you have any health problems that need further clarification?
- Yes
- No
If yes, please explain
Have you had recent exposure to communicable infectious diseases (measles, chickenpox, tuberculosis, prion diseases, and/or travel to endemic areas)?
- Yes
- No
If yes, please explain
In the last 24 hours have you had a new cough, shortness of breath, fever, chills, diarrhea or other influenza type symptoms?
- Yes
- No
If yes, please explain
To the best of my knowledge all preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Referral Information
Whom may we thank for referring you to our practice?*
If other, please explain*
Name of person or office referring you to our practice*
Financial & Insurance Agreement
Payment in full is due at the time of treatment and is considered a part of your commitment to this office. For extensive treatment plans we may be able to offer small in house payment plans with written approval from the clinic and arranged prior to your treatment appointment date. We will gladly file dental claims on your behalf, but we are not a party to any insurance programs or contracts. If you have any questions regarding your insurance we recommend that you contact your dental insurance plan directly. It is important that you be familiar with your benefits to eliminate any disappointments with coverage and reimbursement. Your benefit coverage is a contract between yourself, your employer and the insurance company. Per the Privacy Act, your dental plan information is considered “confidential medical information” and as such it will not be released to us, as your dental care provider. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written financial agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
Intials*
Appointment Policy
In order to be fair to both our team members and to all of our patients, we do require that you notify our office with at least two business days notice for any appointment changes or cancellations. Failure to provide this notice will result in a $61.00 / hour missed appointment charge.
Intials*
Contact Consent
I agree*
- Agree
By clicking the button below, I agree to allow Dentrix Dental to contact me via email.
Consent for Services
I hereby authorize the Dentist to perform the necessary services for prevention and treatment of dental disease and will assume responsibility for associated fees. As a condition of your treatment by this office, financial arrangements must be made in advance. I understand that dental fees can be extended for a period of 3 months from the date of service. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written financial agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.
Signature of patient, parent or guardian*
Date*
Relationship to patient*

Our Dentists are Accepting New Patients in Calgary NW

New Patient Form

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