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403- 936-8432
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Schedule
Online

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.

    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)



    At what point would you like us to initiate treatment? (Please check all that apply)



    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 *

    Grinding *

    Headaches *

    Facial Pain *

    Congenital Heart Disease *

    Clenching *

    Jaw Pain *

    Kidney Trouble *

    Heart Murmur *

    Sensitive Teeth *

    Jaw Popping *

    Radiation/Chemotherapy *

    High Blood Pressure *

    Neck Pain *

    Limited Opening *

    Epilepsy/Seizures *

    Mitral Valve Prolapse *

    Bell's Palsy *

    Congested Ears *

    Diabetes *

    Artificial Heart Valve *

    Difficulty Swallowing *

    Dizziness *

    Hepatitis *

    Pacemaker *

    Difficulty Chewing *

    Ringing Ears *

    AIDS/HIV *

    Stroke *

    Trigeminal Neuralgia *

    Loose Tooth *

    Sickle Cell Disease *

      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.

        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)



        At what point would you like us to initiate treatment? (Please check all that apply)



        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 *

        Grinding *

        Headaches *

        Facial Pain *

        Congenital Heart Disease *

        Clenching *

        Jaw Pain *

        Kidney Trouble *

        Heart Murmur *

        Sensitive Teeth *

        Jaw Popping *

        Radiation/Chemotherapy *

        High Blood Pressure *

        Neck Pain *

        Limited Opening *

        Epilepsy/Seizures *

        Mitral Valve Prolapse *

        Bell's Palsy *

        Congested Ears *

        Diabetes *

        Artificial Heart Valve *

        Difficulty Swallowing *

        Dizziness *

        Hepatitis *

        Pacemaker *

        Difficulty Chewing *

        Ringing Ears *

        AIDS/HIV *

        Stroke *

        Trigeminal Neuralgia *

        Loose Tooth *

        Sickle Cell Disease *

        587-900-0347