Emergency Dental Clinic
Call us today 780-250-0877

New Patient Forms

The following forms can be downloaded to your computer and printed at home. By filling out these forms ahead of time you will save significant time on your visit. If you have any questions when filling out the form, please do the best you can, and our staff will assist you with your questions on the day of your appointment.

New Patient Forms - PDF files
  Medical History Form
  Records Release Form

Technical Note:
Our online forms use the Adobe Acrobat Plugin.
Please download the free plug-in from Adobe's website if it is not already installed on your system. It is important that you have the latest version, in order to open, fill and save our forms.

  Get Adobe Reader

Request an
Appointment
make the first step for a better smile!
Looks good!
Please provide your full name
Looks good!
Please provide a valid phone number
Looks good!
Please provide a valid email address
Looks good!
Please select one of the above
Looks good!
How did you hear about us?
Looks good!
Please write your message here
1 + 2
Looks good!
Please answer the math question