105 MacCosham Lofts 10301-109 St.
Edmonton, AB T5J 1N4

+1 587-400-7558

CREATING BEAUTIFUL SMILES
WE ARE COMMITTED TO YOU AND YOUR SMILE
COMFORTABLE DENTAL CARE FOR ALL AGES
BRINGING OUT THE BEST IN YOU
GET READY TO SMILE ANYTIME, ANYWHERE.
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Welcome to Our Dental Office

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the 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.

Registration Information

This information will enable us to maintain communication with you.

Medical Priority

This information will enable us to make any essential contacts.

Financial Information

This information is necessary to process invoices and apply payments. Please complete all information if different than above.

Primary Dental Insurance

(If information required by office)

Dental History

Have you ever had any of the following?

1

Medical History

INDICATE WHICH OF THE FOLLOWING YOU PRESENTLY HAVE OR EVER HAD:

Has the CHILD PATIENT recently had any of the following: (indicate approximate date)

GENERAL RELEASE (Please sign after completing medical questionnaire.)

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 receive 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 authorize the dentist to perform diagnostic procedures as may be required to determine ncecessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

Contact Dr. Fialka-Eshenko for
a consultation today!
Accepting new patients

+1 587-400-7558

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