For our new patients, please either fill out the 2-part online New Patient form below or, if you prefer, click here to for a printable version that you can complete prior to your first visit. You can either fax the completed form to us at 780-434-6123 or bring it with you to your first visit.

Patient Registration


Last Name, First Name
Home Address
City / Prov / Postal Code
Date of Birth
Home Phone
Business Phone / Extension
Whom may we thank for referring you to our office?

IF PATIENT IS A CHILD
Father's Name
Father's Address.
City / Prov / Postal Code
Father's Home Phone
Business Phone
Mother's Name
Mother's Address
City / Prov / Postal Code
Mother's Home Phone
Mother's Business Phon

PERSON TO CONTACT IN CASE OF EMERGENCY
Name
Home Phone
Business Phone
Address
City / Prov / Postal Code

ACCOUNT INFORMATION
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
Name
Occupation
Employer

FINANCIAL RESPONSIBILTY
I understand that I am responsible for fees assoiciated with treatment performed including those not covered by my dental plan, if any. Payment is due on day of service unless other arrangements have been made.
Patient's (Parent's) Signature
Date
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