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Patient FormsAll Ages Welcome

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New Patient Forms

New Child Patient Form
New Teen Patient Form
New Adult Patient Form

New Child Patient Form

Child's Name*
First Last
Preferred Name
Gender
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Home Phone*
Cell Phone*
Child's Health Care Number
Child's Doctor Name
Child's Doctor Phone

Parent Information
Name
First Last
Middle Name
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Home Phone
Cell Phone
Work Phone
Email*
Employer
How do you prefer to be contacted?
How did you hear about us?
This information greatly helps us.
Financing Options
Are you interested in Dental Financing or Payment Plan?
- Yes
Dentist Preference
Hygienist Preference

Dental Coverage
Do you have Dental Coverage?*
- Yes
- No
I give online consent to Bayside Dental and Orthodontics to speak with my insurance company(s) on my behalf to get my dental/ortho coverage information.*
- Yes
- No
I understand it is my responsibility to provide Bayside Dental and Orthodontics, correct insurance information, including any changes to my plan.*
- Yes
- No
I am responsible to know how my plan works and for any co payments my insurance does not cover or is limited too.*
- Yes
- No
I consent to paying my co payments in full after each appointment.*
- Yes
- No
Signature*
I understand my insurance company may require a predetermination from Bayside Dental and Orthodontics to find out dental/ortho coverage information. I give online consent to Bayside Dental and Orthodontics to send a predetermination to my insurance company(s) .*
- Yes
- No
Signature*
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Is there a second coverage?*
- Yes
- No
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Do you want us to Direct bill your insurance?*
- Yes
- No
Direct Billing Contract*
1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
I have read this document in full and consent to the financial agreement
Signature*

Medical History
General*
- Is your child in good health?
- Is he/she currently taking and medications or drugs?
- Does he/she have any allergies?
- Are you aware of any medical problems?
- Has your child ever been hospitalized, had general anesthesia or ER visits?
- Have you ever been told your child needs antibiotics before dental treatment?
- None of the above
Has your child experienced an unusual reaction to the following:*
- Local anaesthetic (freezing)
- Aspirin
- Penicillin
- Latex
- Sulfa Drugs
- None of the above
Are your child's immunizations current?
- Yes
- No

Specific History
Has your child been treated for any of the following:*
- Heart murmur
- Stomach problems
- Joint replacement
- Mental or nervous disorder
- High blood pressure
- Low blood pressure
- Epilepsy or seizures
- Kidney disease
- Heart attack or heart problems
- Recurrent headaches
- Tuberculosis
- Diabetes
- Cancer
- Asthma
- Hay Fever
- Cold Sores
- Sinus Problems
- Blood disorders
- Jaundice
- Rheumatic Fever
- HIV or AIDS
- Thyroid Disease
- Cleft lip/palate
- Snoring
- Autism
- None of the above
Does your child have any of the following:
Has your child been vaccinated against COVID-19?
- Yes
- No
Hepatitis A B C
Are you interested in sedation?
- Yes
- No
If yes, which type?
Other issues:
- Congenital birth defects
- Physical delays
- Mental delays
- Hearing difficulties
- Seeing difficulties
- None of the above

Dental History
Reason for today's visit?*
Has you child ever been to the dentist?
- Yes
- No
Date of last visit? (Approximate)
Date of last cleaning? (Approximate)
Date of last exam? (Approximate)
Previous dentist or city of previous dentist?*
Were you happy with your treatment there?*
- Yes
- No
If no, why were you unhappy? How can we make your child's experience better?
Do you have any emotional concerns about your dentist visit?
- Fear
- Discomfort
- Time
- Cost
- Embarrassment
Do you have concerns about any of the following:
- Cavities
- Toothache
- Trauma
- Colour of teeth
- Orthodontics
- Sensitive teeth
- Crowding
- Grinding teeth
- Gum infection
- Mouth breathing
- Jaw sounds
- Other
Has your child experienced any of these:
- Has your child ever injured their teeth?
- Has your child had a bad experience at the dentist?
- Does your child snack frequently?
- Does your child go to bed with a bottle or sippy cup?
- Has your child had dental anaesthesia (or a needle in the mouth) before?
- Were there any problems?
- Does your child play competitive sports with a risk of dental trauma or concussions?

Medications
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Allergies:
Is there anything in your medical or dental history that is not listed and we should know about?

Consent*
I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
Yes, I agree*
Cancellation Policy*
We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
Yes, I have read and understand the cancellation policy*
Name*
Signature*
Email
This field is for validation purposes and should be left unchanged.

Δ

New Teen Patient Form

Teen's Name*
First Last
Preferred Name
Gender
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Home Phone*
Cell Phone*
Teen's Health Care Number
Teen's Doctor Name
Teen's Doctor Phone

Parent Information
Name
First Last
Middle Name
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Home Phone
Cell Phone
Work Phone
Email*
Employer
How do you prefer to be contacted?
How did you hear about us?
This information greatly helps us.
Financing Options
Are you interested in Dental Financing or Payment Plan?
- Yes
Dentist Preference
Hygienist Preference

Dental Coverage
Do you have Dental Coverage?*
- Yes
- No
I give online consent to Bayside Dental and Orthodontics to speak with my insurance company(s) on my behalf to get my dental/ortho coverage information.*
- Yes
- No
I understand it is my responsibility to provide Bayside Dental and Orthodontics, correct insurance information, including any changes to my plan.*
- Yes
- No
I am responsible to know how my plan works and for any co payments my insurance does not cover or is limited too.*
- Yes
- No
I consent to paying my co payments in full after each appointment.*
- Yes
- No
Signature*
I understand my insurance company may require a predetermination from Bayside Dental and Orthodontics to find out dental/ortho coverage information. I give online consent to Bayside Dental and Orthodontics to send a predetermination to my insurance company(s).*
- Yes
- No
Signature*
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Is there a second coverage?*
- Yes
- No
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Do you want us to Direct bill your insurance?*
- Yes
- No
Direct Billing Contract*
1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
I have read this document in full and consent to the financial agreement
Signature*

Medical History
General*
- Is your teen in good health?
- Is he/she currently taking and medications or drugs?
- Does he/she have any allergies?
- Are you aware of any medical problems?
- Has your teen ever been hospitalized, had general anesthesia or ER visits?
- Have you ever been told your child needs antibiotics before dental treatment?
- None of the above
Has your teen experienced an unusual reaction to the following:*
- Local anaesthetic (freezing)
- Aspirin
- Penicillin
- Latex
- Sulfa Drugs
- None of the above
Are your teen's immunizations current?
- Yes
- No

Specific History
Has your teen been treated for any of the following:*
- Heart murmur
- Stomach problems
- Joint replacement
- Mental or nervous disorder
- High blood pressure
- Low blood pressure
- Epilepsy or seizures
- Kidney disease
- Heart attack or heart problems
- Recurrent headaches
- Tuberculosis
- Diabetes
- Cancer
- Asthma
- Hay Fever
- Cold Sores
- Sinus Problems
- Blood disorders
- Jaundice
- Rheumatic Fever
- HIV or AIDS
- Thyroid Disease
- Cleft lip/palate
- Snoring
- Autism
- None of the above
Does your teen have any of the following:
Has your teen been vaccinated against COVID-19?
- Yes
- No
Hepatitis A B C
Are you interested in sedation?
- Yes
- No
If yes, which type?
Other issues:
- Congenital birth defects
- Physical delays
- Mental delays
- Hearing difficulties
- Seeing difficulties
- None of the above

Dental History
Reason for today's visit?*
Has you teen ever been to the dentist?
- Yes
- No
Date of last visit? (Approximate)
Date of last cleaning? (Approximate)
Date of last exam? (Approximate)
Previous dentist or city of previous dentist?*
Were you happy with your treatment there?*
- Yes
- No
If no, why were you unhappy? How can we make your teen's experience better?
Do you have any emotional concerns about your dentist visit?
- Fear
- Discomfort
- Time
- Cost
- Embarrassment
Do you have concerns about any of the following:
- Cavities
- Toothache
- Trauma
- Colour of teeth
- Orthodontics
- Sensitive teeth
- Crowding
- Grinding teeth
- Gum infection
- Mouth breathing
- Jaw sounds
- Other
Has your teen experienced any of these:
- Has your teen ever injured their teeth?
- Has your teen had a bad experience at the dentist?
- Does your teen snack frequently?
- Does your teen go to bed with a bottle or sippy cup?
- Has your teen had dental anaesthesia (or a needle in the mouth) before?
- Were there any problems?
- Does your teen play competitive sports with a risk of dental trauma or concussions?

Medications
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Allergies:
Is there anything in your medical or dental history that is not listed and we should know about?

Consent*
I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
Yes, I agree*
Cancellation Policy*
We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
Yes, I have read and understand the cancellation policy*
Parent / Guardian Name*
Signature*
Email
This field is for validation purposes and should be left unchanged.

Δ

New Adult Patient Form

Name*
First Last
Preferred Name
Title
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Home Phone*
Cell Phone
Work Phone
Email*
How do you prefer to be contacted?
Health Care Number
Employer
Doctor Name
Doctor Phone
How did you hear about us?
This information greatly helps us.
Financing Options
Are you interested in Dental Financing or Payment Plan?
- Yes
Dentist Preference
Hygienist Preference

Dental Coverage
Do you have Dental Coverage?*
- Yes
- No
I give online consent to Bayside Dental and Orthodontics to speak with my insurance company(s) on my behalf to get my dental/ortho coverage information.*
- Yes
- No
I understand it is my responsibility to provide Bayside Dental and Orthodontics, correct insurance information, including any changes to my plan.*
- Yes
- No
I am responsible to know how my plan works and for any co payments my insurance does not cover or is limited too.*
- Yes
- No
I consent to paying my co payments in full after each appointment.*
- Yes
- No
Signature*
I understand my insurance company may require a predetermination from Bayside Dental and Orthodontics to find out dental/ortho coverage information. I give online consent to Bayside Dental and Orthodontics to send a predetermination to my insurance company(s).*
- Yes
- No
Signature*
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Is there a second coverage?*
- Yes
- No
What is name of the insurance company?
Name of Insured
Date of Birth
MM slash DD slash YYYY
Plan / Policy Number
Certificate / ID Number
Do you want us to Direct bill your insurance?*
- Yes
- No
Direct Billing Contract*
1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Bayside Dental and Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

3. I have read this document in full and consent to the following financial agreement:

4. I, authorize Bayside Dental and Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
I have read this document in full and consent to the financial agreement
Signature*

Person Responsible for Payment
Info of person responsible for payment of account (if different from above)
Name
First Last
Middle Name
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Home Phone
Cell Phone
Work Phone

Medical History
General*
- Are you under the care of a physician?
- Are you currently taking and medications or drugs?
- Do you have any allergies?
- Are you aware of any medical problems?
- None of the above
Reactions*
- Local anaesthetic (freezing)
- Aspirin
- Penicillin
- Latex
- Sulfa Drugs
- None of the above
Female Specific*
- Women Only - Do you take birth control pills?
- Women Only - Are you Pregnant?
- None of the above

Specific History
Do you, or have you had, any of the following:*
- Heart murmur
- Stomach problems
- Joint replacement
- Mental or nervous disorder
- High blood pressure
- Low blood pressure
- Epilepsy or seizures
- Stroke
- Heart attack or heart problems
- Drug or alcohol addiction
- Tuberculosis
- Diabetes
- Cancer
- Asthma
- Hay Fever
- Cold Sores
- Sinus Problems
- Arthritis
- Jaundice
- Rheumatic Fever
- HIV or AIDS
- Thyroid Disease
- Hyperthyroidism
- Hypothyroidism
- Venereal Disease
- None of the above
Hepatitis A B C
Do you smoke?
Have you been vaccinated against COVID-19?
- Yes
- No
Do you bruise or bleed easily?
- Yes
- No
Do you have frequent or severe headaches?
- Yes
- No
Do you have hearing difficulties?
- Yes
- No

Dental History
Reason for today's visit?*
How often do you visit the dentist?
Date of last visit? (Approximate)
Date of last cleaning? (Approximate)
Date of last exam? (Approximate)
Previous dentist or city of previous dentist?*
Were you happy with your treatment there?*
- Yes
- No
If no, why were you unhappy?
Do you have any emotional concerns about your dentist visit?
- Fear
- Discomfort
- Time
- Cost
- Embarrassment
Are your teeth sensitive to:
- Hot
- Sweet
- Cold
- Other
Do your gums bleed when:
- Brushing
- Flossing
- Spontaneously
To your knowledge do you grind or clench your teeth?

Have you ever been sedated? If yes, select which types of sedation you've previously had.
- Nitrous
- Oral sedation
- IV sedation
- Never been sedated
Are you interested in sedation?
- Yes
- No
If yes, which type?
Are you interested in, or have you thought about any of the following:
- Invisalign or Orthodontics (Braces)
- Closing spaces between teeth
- Replacing missing teeth
- Implants
- Tooth whitening
- Sports Mouthguard
- Crowns (Caps)
- Improved Gum Line
- Improving your smile
- Improving bad breath
- Repairing chipped teeth

Medication
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Name of medication
Reason for medication
Dosage
Allergies:
Is there anything in your medical or dental history that is not listed and we should know about?

Consent*
I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
Yes, I agree*
Cancellation Policy*
We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
Yes, I have read and understand the cancellation policy*
Name*
Signature*
Comments
This field is for validation purposes and should be left unchanged.

Δ

BaysideDental&Orthodontics

Experienced dentists bringing the latest advancements and skills in oral care to Airdrie, Alberta.

info@airdriebaysidedental.com

airdriebaysidedental.com

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Dr. Randolph M. Headley

© 2025 Bayside Dental & Orthodontics. Website by

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© 2025 Bayside Dental & Orthodontics. Website by

ABOUT
SITEMAP
BACK TO TOP