Your First Appointment

What to expect?

Your first appointment with Dr. Westersund could be the first step to life lasting dental health.
After booking an appointment, we will:

• introduce you to one of our consultants to discuss your needs or treatment
• take you on a tour around the office
• take digital photographs and radiographs
• perform a thorough exam by Dr. Westersund
• discuss any treatment options
• provide you with an overview of cost

We would like to give you the best possible care, but ... then we need to know more about you! Detailed information about your current health, habits and requirements (or medication) will provide us with clarity which avoids misinterpretation. Rest assured, all your information is safe with us and strictly confidential.

You may choose to complete our medical/dental form below now - or - at our office.

Take action today - your welcome!


Dr. Curtis Westersund

* fields are mandatory

General Health:   Please check:

GOOD FAIR POOR
Last physical:   YYYY-MM-DD
This Year
Last Year
More Than 1 Year Ago
Longer Ago
Current Physician:  
Name:
City:
Phone:
Last dental visit:   YYYY-MM-DD
This Year
Last Year
More Than 1 Year Ago
Longer Ago
Last dental cleaning:   YYYY-MM-DD
This Year
Last Year
More Than 1 Year Ago
Longer Ago
Last X-rays:   YYYY-MM-DD
This Year
Last Year
More Than 1 Year Ago
Longer Ago
Previous dentist:  
Name:
City:
Phone
*Do you smoke?   yes
no
*If yes, how much per day?  
*Are you allergic to any medications?   yes
no
*If yes, names of medications:  
*Do you require medications prior to dental treatment?   yes
no
If yes, what?  
Medications 1:  
Taken for:  
Medications 2:  
Taken for:  
Medications 3:  
Taken for:  

* fields are mandatory

 
YES/NO
    
YES/NO
       
*Anemia
*Heart disease or attack
*Angina Pectoris
*Heart murmur
*Arthritis/rheumatism
*Heart pacemaker
*Artificial Heart valve
*Heart rhythm disorder
*Artifical joints (hip,knee)
*Heart surgery
*Blood disorder
*Hepatitis A
*Bronchitis
*Hepatitis B
*Cancer
*Hepatitis C
*Circulation problems
*HIV
*Congenital heart lesions
*High/low blood pressure
*Cortisone/steroids
*Hodgkins disease
*Diabetes
*Hyper-(hypo) Glycemia
*Emphysema
*Hypertension
*Epilepsie or seizures
*Jaundice
*Fainting or dizzy spells
*Kidney disease
*Glandular disorders
*Latex allergy
*Glaucoma
*Liver disease
*Head/neck injuries
*Lung disease

* fields are mandatory

 
YES/NO
   
*Major accidents
*Malignant Hyperthermia
*Metal allergy
*Mitral valve prolapse
*Organ transplant /medical implant
*Psychiatric treatment
*Radiation treatment / chemotherapy
*Rheumatic/Scarlet fever
*Sickle cell disease
*Sinus trouble
*Stomach/Intestinal problems
*Stroke
*Thyroid disease
*Tuberculosis
*Ulcers

 

If you have entered 'yes' to any of the above, please explain:


If you have or have had any disease, condition or problem not listed, please list and explain:



* fields are mandatory

Woman:
*Are you pregnant? 		  yes
no
*If yes, months?  
*If no, nursing?   yes
no
*Taking birth control pills?   yes
no
What are your hobbies?  
Special interests?  
How did you find us?   Internet
LRT ad
Magazine ad
Referral by Family Member or Friend
Other:


I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed you have my permission to ask the respective health care provider or agency who may release such information to you.


At the Westersund Centre for Aesthetic Dentistry, though our focus is on appearance-related dentistry, we deliver full-service dentistry as well. With flexible payment plans as well as phasing treatment over time, you can achieve spectacular long-term results. Thank you so much for the opportunity to be of service.


* fields are mandatory

*Last name:  
*First name:  
Preferred name:  
Date of birth:   YYYY-MM-DD
Sex:   male female
*Home Address:  
*City:  
Province:  
*Postal Code:  
Country:  
*Home phone number:  
Business phone number:  
Cell phone number:  
*E-mail address:  
Do you prefer email?   yes
no
Name of employer:  
Occupation:  
Business address:  
City:  
Province:  
Postal Code:  
Country:  
Family members that are patients:   1.
2.
3.
in case of emergency, contact (close relative):  
Address:  
City:  
Phone:  
Email:  



Primary Dental Insurance

Subscriber's name:  
Date of Birth:   YYYY-MM-DD
Relationship to subscriber:  
Insurance year end/Calendar year:  
Employer  
Insurance Company:  
Address:  
City:  
Phone  
Group, Policy or Contact number:  
Fee Schedule:  



Secondary Dental Insurance

Subscriber's name:  
Date of Birth:   YYYY-MM-DD
Relationship to subscriber:  
Insurance year end/Calendar year:  
Employer  
Insurance Company:  
Address:  
City:  
Phone  
Group, Policy or Contact number:  
Fee Schedule:  

 

Consent for Treatment

I hereby authorize Dr. Westersund or his designated team member to take x-rays, stutly models, photographs and other diagnostic aids deemed appropiate by Dr. Westersund to make a thorough diagnosis of my (or my dependants) dental needs. Upon such diagnosis, I authorized Dr. Westersund to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agerits embodies certain risks. i undertand that I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf or my dependants. i understand that payment is due at time of service and any insurance claims will be filed and reimbursed to me directly.

I accept Dr. Westersund's Terms & Conditions

 

Personal Information Consent Form

We are committed to protecting the privacy of our patients' personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In adition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers and email addresses. (collectively referred to as "Contact Information"). Contact Information is collected and used for the following purposes:

  • to open and update patient files.
  • to invoice patients for dental services, to process credit card payments or to collect unpaid accounts.
  • to process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
  • to send reminders to patients concerning the need for further dental examination or treatment.
  • to send patients informational material about our dental practice.

Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.

Financial Information may be collected in order to make arrangements for the payment of dental services.

We collect information from our patients about their health history, their family health history, physical condition and dental treatments. (Collectively referred to as "Medical Information"). Patients' Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patients Medical Information is disclosed:

  • to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf.
  • to other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
  • to toher dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental spcialist for treatment.
  • to other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
  • to other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted acces as part of the due diligence proces to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

 
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