New Patient Form - Medical History


1. Are you in Good Health

2. Have you had an unusual reaction to drugs/medications? To what? i.e. Penicillin

3. Is your physician treating you now?


4. Are you taking any medication? (prescription or over the counter)

Please list
Pharmacy contact info

5. Do you smoke or use tobacco products?

6. Do you use recreational medical marijuana?

7. Do you have any allergies?

Please list

8. Do you experience shortness of breath?

9. Have you gained or lost excessive weight recently?

10. Do you have heart disease or murmur? Heart Attack?

If so, when?

11. Are your ankles often swollen?

12. Have you ever had radiation treatment?

13. For women only, are you any of the following?:




14. Have you had any of the following? (check all that apply):

Heart trouble
High Blood Pressure
Rheumatic Fever
Blood disorders
Thyroid trouble
Kidney trouble
Pic Line
Liver trouble


New Patient Form - General Inoformation

1. Birthday

2. Address

3. Postal Code

4. Home Phone

5. Work Phone

6. Cell Phone

7. Email

8. Health Card Number

9. Spouse/Parent Name

10. Employer/Occupation

11. Referred by:

This is to certifiy that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and i will assume responsibility for fees associated with those procedures. I acknowledge reviewing the College Park Dental privacy policy and understand my rights of privacy with respect to me (and any dependent children) personal information. I further consent to the collection, use and disclosure of my (or dependent child's) personal information;
(please check the boxes)

To provide dental services

To maintain communications with healthcare specialists and to provide me (us) with information and follow up respecting my dental care;

To communicate with my insurance plan(s) to facilitate the processing of my claims;

For the uses, purposes, and disclosures described in the privacy act.;

Dental Questionaire

1. Have you had any of the following?:

a. Orthodonic treatment (teeth straightened)

b. Surgery to teeth, jaws or face

c. Trauma to teeth, jaws or face

d. Periodontal (gum) treatment

2. Do you now or have you ever had sinus problems?

3. Have you ever had abnormal bleeding after an extraction or a cut?

4. Have you ever had a bad reaction to freezing or freezing that did not take?

5. Do you grind your teeth while awake or asleep?

6. Do you have any jaw joint problems: e.g. clicking, popping, pain?

7. Do you suffer from frequent headaches?

8. Are your teeth sensitive to hot or cold?

9. Are you satisfied with the appearance of your teeth?




College Park Dental
3929 8th St E,
Saskatoon, SK
S7H 5M2

Phone: (306) 955-4611