The information requested on this Questionnaire, Dental History and Medical History is essential to providing you with the safest and highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

Personal Information






Mr.Mrs.MissMs.

SingleMarriedDivorcedSeparatedWidow

YesNo





MaleFemale










YesNo



FamilyFriendClose to home/workDrive byInternet/WebsiteOther




Insurance Information







SelfSpouseChildOther






SelfSpouseChildOther

Medical History



Please answer Yes or No to each question, if YES, please explain. If unsure of a question, please consult with a comfort care dental professional.



YesNo















Indicate which of the following you presently have or ever had
A.I.D.SAnemiaAngina pectorisArthritis/rheumatismArtificial heart valveArtificial joints (hip/knee)Blood disordersBronchitisCancerCirculation problemsCongenital heart lesionsCortisone/steroidsCrohn's diseaseDiabetesEmphysemaFainting or dizzy spellsGlandular disorders
GlaucomaHead/neck injuriesHeart disease or attackHeart murmurHeart pacemakerHeart rhythm disorderHeart surgeryHepatitis A B CHerpesHodgkin's diseaseHyper (hypo) GlycaemiaHypertensionInflammatory bowel diseaseJuandiceKidney diseaseLiver diseaseLung disease
LupusMalignant hypothermiaMental/nervous disorderMitral valve prolapseOrgan Transplant/medical implantPsychiatric treatmentRadiation treatment/chemotherapyScarlet fever/rheumatic feverSickle cell diseaseSinus troubleStomach/intestinal problems/ulcersStrokeThyroid diseaseTuberculosisVenereal diseaseNone of the above


Has the CHILD PATIENT recently had any of the following
MeaslesMumpsChickenpoxStrep throatTonsillitis

Women only

YesNo


YesNo

YesNo

YesNo

Dental History

Please answer Yes or No to each question, if YES, please explain. If unsure of a question, please consult with a comfort care dental professional.





Have you ever had any of the following?















Have you ever experienced any of the following jaw problems?





Do you have any of the following habits?

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo








General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and received answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided I will advise this dental office. I authorized the dental provider to perform diagnostic procedures as needed to determine necessary treatment. As a patient, I understand that I have the right to:

Be advised of the benefits, options and risks of any dental procedure, ask questions and receive complete answers regarding my dental health, and to make an informed decision to accept or decline recommended treatment.


Privacy Policy

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cellular phone numbers and email addresses (collectively referred to as “Patient Contact information”). Patient contact information is collected and used for the following purposes:

  • To open and update patient files
  • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
  • To process claims for payment or reimbursement for third-party health benefits providers and insurance companies
  • To send reminders to patients concerning the need for further dental examination or treatment
  • To send patients information material about our dental practice

Patient contact information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf. Financial information will be collected in order to make arrangements for the payment of dental services provided, unless the dental services are paid for in full at the time of visit.

We collect information from our patients about their health history, their family health history, physical condition, and previous dental treatments (collectively referred to as “medical information”). Patients’ medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients’ medical information is disclosed:

  • To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
  • To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to is obtaining the second opinion
  • To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment
  • To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
  • To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment
  • www.comfortcare.ca and any electronic submissions through this site allow us access to personal information such as, email addresses, IP addresses, names, phone numbers and dental requirements. Website information is collected and used for the purpose of booking/revising appointments.

If information is no longer required, all pertinent documents are destroyed using the services of Shred-It, an on-site, secure document destruction program developed specifically to deal with regulatory privacy and confidentiality requirements.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest. I consent to the collection, use and disclosure of my personal information as set out above.



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