New Patient / Health History Form | Cityview Periodontal Centre.

Please note that this form must be filled out within 40 minutes of visiting this page.

Patient Information

Last Name

First Name

Middle Name

Home Phone

Cell Phone

Address

City/Town

Postal Code

Sask Health Card #

Date of Birth

Gender (male/female/other)

Emergency Contact Information

Last Name

First Name

Middle Name

Relationship

Home Phone

Cell Phone

Dental Information Medical Information

Physician Name

Are you under the care of a physician? Yes No

Date of last physical exam?

Are you taking any prescriptions/over the counter medication? (Please list below) Yes No

Have you been hospitalized in the last 5 years? Yes No

Reason

Height

Weight

Are you in good health? Yes No

Allergies

Allergies
Aspirin Codeine Sulfa Local Anesthetic Demerol Penecilin Latex Environment

Other Allergies (please list)

New Patient Form

Name of Pharmacy

Town/City

Office policy

By submitting this form, you acknowledge and agree to our office policies for billing and cancellations:

Cityview Periodontal does not offer direct billing.
Appointment cancellations MUST be made within 3 business days of your scheduled appointment time to avoid a $100 rebooking fee.

I acknowledge and accept the above terms.