Dr. Greg Broyde BSc, DDS
Dr. Navdeep Dhaliwal BSc, DDS
526 Riverfront Ave SE
Calgary AB T2G 1E4
Ph: 403 263 9014

Patient Information

The following information is required by East Village Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Preference


Person Responsible for Payment

Info of person responsible for payment of account (if different from above)


Medical History


Specific History

Do you, or have you had, any of the following:


Medications

List all medications, supplements, and or vitamins taken within the last two years

Please advise us in the future of any changes in your medical history or any medications you may be taking.


Dental History

Personal History

Gum and Bone

Tooth Structure

Bite and Jaw Joint

Airway and Sleep

Smile Characteristics







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.