New Patient Form By providing detailed information about yourself and your medical history, you will save time when you visit our office. Your information is secure and will be kept strictly confidential. First Name : Last Name : Address : City : Province : Postal Code : Phone Number ex. (403) 543-4600: Daytime Phone Number: Email Address: Date of Birth: Height: —Please choose an option—StandardMetric Height: Weight: —Please choose an option—StandardMetric Weight: Do you have any areas of concern? * Tell us in your opinion, what you think the present state of health your mouth is in: * ExcellentVery GoodAveragePoorUgly How healthy do you want us to get your mouth?: * Don't really careAverageThe best it can be Tell us about your good dental experiences, what do you look for in a practice, what has pleased you in the past Tell us about any bad dental experiences, what do you dislike in a practice, Have you had any past negative experiences? What caused you to leave your last dental office? If there was one thing you could change about your smile, what would it be? What would it take for you to trust us to be your dentist? Name and number of Previous Dentist How did you find out about Langdon Dental? GoogleFacebookPrint adFriend or family referralOther What do you already know about our office and what are your expectations? Has fear ever been an issue for you in a dental office? * YesNo Has time ever been a factor in getting your dental work done? * YesNo Has the cost of dental treatment been a concern for you? * YesNo What can we do to help you with this? We have the unique ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you? (please check all that apply) As a general dentist As a cosmetic dentist As a functional (TMD/TMJ Relief) dentist At what point would you like us to initiate treatment? (Please check all that apply) When my tooth hurts or breaks When something is worsening When something isn't ideal What quality of dentistry do you want us to recommend? Just patch itAverage Ideal/the best Is there any additional information you would like us to know? Have you been under the care of a medical doctor during the past two years? * YesNo If so, for what? Physician's Name Physician's Phone Number ex. (403) 543-4600 Are you taking any medication now, including regular dosages of aspirin, supplements, vitamins or herbal remedies? * YesNo If yes, please list name and dosage Are you aware of having an allergic reaction to any medication or substance? * YesNo If yes, please list Have you had X-rays in the last year? * YesNo Note: If yes, please contact the dental office that took your X-rays and request that they send those files to [email protected].Our team would like to review your X-rays prior to your scheduled appointment. * Indicate which of the following you have had, or have at present. Heart Concerns * YesNo Grinding * YesNo Headaches * YesNo Facial Pain * YesNo Congenital Heart Disease * YesNo Clenching * YesNo Jaw Pain * YesNo Kidney Trouble * YesNo Heart Murmur * YesNo Sensitive Teeth * YesNo Jaw Popping * YesNo Radiation/Chemotherapy * YesNo High Blood Pressure * YesNo Neck Pain * YesNo Limited Opening * YesNo Epilepsy/Seizures * YesNo Mitral Valve Prolapse * YesNo Bell's Palsy * YesNo Congested Ears * YesNo Diabetes * YesNo Artificial Heart Valve * YesNo Difficulty Swallowing * YesNo Dizziness * YesNo Hepatitis * YesNo Pacemaker * YesNo Difficulty Chewing * YesNo Ringing Ears * YesNo AIDS/HIV * YesNo Stroke * YesNo Trigeminal Neuralgia * YesNo Loose Tooth * YesNo Sickle Cell Disease * YesNo First Name: * Last Name: * Address: * City: * Province: * Postal Code Phone Number ex. (403) 543-4600: * Daytime Phone Number: Email Address * Date of Birth: * Height—Please choose an option—StandardMetric Height Weight—Please choose an option—StandardMetric Weight Do you have any areas of concern? * Tell us in your opinion, what you think the present state of health your mouth is in: *ExcellentVery GoodAveragePoorUgly How healthy do you want us to get your mouth?: *Don't really careAverageThe best it can bePoorUgly Tell us about your good dental experiences, what do you look for in a practice, what has pleased you in the past Tell us about any bad dental experiences, what do you dislike in a practice, Have you had any past negative experiences? What caused you to leave your last dental office? If there was one thing you could change about your smile, what would it be? What would it take for you to trust us to be your dentist? Name and number of Previous Dentist How did you find out about Langdon Dental?GoogleFacebookFriend or family referralOther What do you already know about our office and what are your expectations? Has fear ever been an issue for you in a dental office? *YesNo Has time ever been a factor in getting your dental work done? *YesNo Has the cost of dental treatment been a concern for you? *YesNo What can we do to help you with this? We have the unique ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you? (please check all that apply)As a general dentistAs a cosmetic dentistAs a functional (TMD/TMJ Relief) dentist At what point would you like us to initiate treatment? (Please check all that apply)When my tooth hurts or breaksWhen something is worseningWhen something isn't ideal What quality of dentistry do you want us to recommend?Just patch itAverageIdeal/the best Is there any additional information you would like us to know? Have you been under the care of a medical doctor during the past two years? *YesNo If so, for what? Physician's Name Physician's Phone Number ex. (403) 543-4600 Are you taking any medication now, including regular dosages of aspirin, supplements, vitamins or herbal remedies? *YesNo If yes, please list name and dosage Are you aware of having an allergic reaction to any medication or substance? *YesNo If yes, please list Have you had X-rays in the last year? *YesNo Note: If yes, please contact the dental office that took your X-rays and request that they send those files to [email protected].Our team would like to review your X-rays prior to your scheduled appointment. * Indicate which of the following you have had, or have at present. Heart Concerns *YesNo Grinding *YesNo Headaches *YesNo Facial Pain*YesNo Congenital Heart Disease *YesNo Jaw Pain *YesNo Kidney Trouble *YesNo Heart Murmur *YesNo Sensitive Teeth *YesNo Jaw Popping *YesNo Radiation/Chemotherapy *YesNo High Blood PressureYesNo Neck Pain *YesNo Limited Opening *YesNo Epilepsy/Seizures *YesNo Mitral Valve Prolapse *YesNo Bell's Palsy *YesNo Diabetes *YesNo Artificial Heart Valve *YesNo Difficulty Swallowing *YesNo Dizziness *YesNo hepatitis *YesNo Pacemaker *YesNo Difficulty Chewing *YesNo Ringing Ears *YesNo AIDS/HIV *YesNo Stroke *YesNo Trigeminal Neuralgia *YesNo Clenching *YesNo Loose Tooth *YesNo Sickle Cell Disease *YesNo Congested Ears *YesNo First Name : Last Name : Address : City : Province : Postal Code : Phone Number ex. (403) 543-4600: Daytime Phone Number: Email Address: Date of Birth: Height: —Please choose an option—StandardMetricHeight: Weight: —Please choose an option—StandardMetric Weight: Do you have any areas of concern? * Tell us in your opinion, what you think the present state of health your mouth is in: * ExcellentVery GoodAveragePoorUgly How healthy do you want us to get your mouth?: * Don't really careAverageThe best it can be Tell us about your good dental experiences, what do you look for in a practice, what has pleased you in the past Tell us about any bad dental experiences, what do you dislike in a practice, Have you had any past negative experiences? What caused you to leave your last dental office? If there was one thing you could change about your smile, what would it be? What would it take for you to trust us to be your dentist? Name and number of Previous Dentist How did you find out about Langdon Dental? GoogleFacebookPrint adFriend or family referralOther What do you already know about our office and what are your expectations? Has fear ever been an issue for you in a dental office? * YesNo Has time ever been a factor in getting your dental work done? * YesNo Has the cost of dental treatment been a concern for you? * YesNo What can we do to help you with this? We have the unique ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you? (please check all that apply) As a general dentist As a cosmetic dentist As a functional (TMD/TMJ Relief) dentist At what point would you like us to initiate treatment? (Please check all that apply) When my tooth hurts or breaks When something is worsening When something isn't ideal What quality of dentistry do you want us to recommend? Just patch itAverage Ideal/the best Is there any additional information you would like us to know? Have you been under the care of a medical doctor during the past two years? * YesNo If so, for what? Physician's Name Physician's Phone Number ex. (403) 543-4600 Are you taking any medication now, including regular dosages of aspirin, supplements, vitamins or herbal remedies? * YesNo If yes, please list name and dosage Are you aware of having an allergic reaction to any medication or substance? * YesNo If yes, please list Have you had X-rays in the last year? * YesNo Note: If yes, please contact the dental office that took your X-rays and request that they send those files to [email protected].Our team would like to review your X-rays prior to your scheduled appointment. * Indicate which of the following you have had, or have at present. Heart Concerns * YesNo Grinding * YesNo Headaches * YesNo Facial Pain * YesNo Congenital Heart Disease * YesNo Clenching * YesNo Jaw Pain * YesNo Kidney Trouble * YesNo Heart Murmur * YesNo Sensitive Teeth * YesNo Jaw Popping * YesNo Radiation/Chemotherapy * YesNo High Blood Pressure * YesNo Neck Pain * YesNo Limited Opening * YesNo Epilepsy/Seizures * YesNo Mitral Valve Prolapse * YesNo Bell's Palsy * YesNo Congested Ears * YesNo Diabetes * YesNo Artificial Heart Valve * YesNo Difficulty Swallowing * YesNo Dizziness * YesNo Hepatitis * YesNo Pacemaker * YesNo Difficulty Chewing * YesNo Ringing Ears * YesNo AIDS/HIV * YesNo Stroke * YesNo Trigeminal Neuralgia * YesNo Loose Tooth * YesNo Sickle Cell Disease * YesNo