New Patient Forms 

Due to COVID-19, we are looking to reduce the amount of commonly touched surfaces in the clinic. This includes paper, pens, clipboards, etc.

Please take a moment to fill out the required new patient forms before your visit. All 4 links will need to be completed. 

  1. PERSONAL INFORMATION, INFORMATION CONSENT FORM, AND INSURANCE INFORMATION
     

  2. MEDICAL HISTORY
     

  3. COVID-19 CONSENT
     

  4. FINANCIAL POLICY 
    required to be filled out if taking assignment of benefits
    Please note, if we are direct billing your insurance, we will require to keep a credit card on file. We will collect this information on the day of your appointment.

Below are the forms that will be signed when you come in to the office for your appointment. Make sure to review these before your appointment. 

General Anesthesia/IV Sedation Consent Form
required if having treatment done under general anesthesia or IV sedation
 

Local Treatment Consent Form
required if having treatment done under local anesthetic

 

Financial Agreement
required if taking assignment of benefits

The following will apply for all patients who attend an appointment at our office:

 

  • please text us when you arrive and we will tell you when to come in to the building. Please do not come in unless you were told to.

  • only the patient is allowed in the building

    • if the patient is a minor, only one parent is allowed to accompany the patient

    • if the patient is an adult and is being sedated, only one escort is allowed to accompany the patient

  • the parent/escort will be required to wait in the waiting room and not leave the building

  • there will be instructions on the back door when you arrive, but the instructions are as follows:

    • if you have your own mask, please bring it with you (we can provide one if you don't have one)

    • Parent/Escort - put on face mask 

    • Parent/Escort & Child - use hand sanitizer 

    • Knock on door when you both are ready

    • We will then take both of your temperatures

    • if you are coming with anyone else, we will be required to take their temperatures as well from the vehicle

    • you will then have a seat in our waiting room

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10835 124 Street

Edmonton, AB

T5M 0H4

ph: 780-413-0824

f: 780-482-0560

Monday 8:00am - 4:00pm

Tuesday 8:00am - 4:00pm

Wednesday 8:00am - 4:00pm

Thursday 8:00am - 4:00pm

Friday 8:00am - 4:00pm