Skip to content

About Us
- Our Team
Our Procedures
Patient Information
Contact

About Us
- Our Team
Our Procedures
Patient Information
Contact

Referrals
Register

Referrals
Register

Registration

To save time before your appointment, you can pre-register by filling out and submitting the secure form below. Rest assured that we value your privacy and we will protect your personal data.

Download a Blank Form

Demographic Information
Birth date*
DD slash MM slash YYYY
Age*
Gender*
- Male
- Female
Height*
- ft' in"
- cm
Height
Height
Height
Weight*
- lbs
- kg
Weight
Weight
Patients Name*
First Last
Home address*
City*
Province*
Postal Code*
Primary phone*
Alternate phone
Email
Health care number
Province
If minor, parent or guardian's name
Person responsible for the account*
First Name Last Name
Mailing Address
City
Postal Code
Dental Insurance Information
First Policy

Policy holder's name
First Name Last Name
Policy holder's DOB
DD slash MM slash YYYY
Insurance company
Employer
Group plan/policy number
Division/section number
Policy holder's certificate No.
Second Policy

Policy holder's name
First Name Last Name
Policy holder's DOB
DD slash MM slash YYYY
Insurance company
Employer
Group plan/policy number
Division/section number
Policy holder's certificate No.
Confidential Medical History
Do you have a history of:
Heart Attack*
- Yes
- No
Bleeding or coagulation disorders*
- Yes
- No
Asthma*
- Yes
- No
Heart Congestion or Failure*
- Yes
- No
Blood Transfusion*
- Yes
- No
COPD/Emphysema*
- Yes
- No
Heart Surgery*
- Yes
- No
Anemia, Sickle Cell Disease*
- Yes
- No
Obstructive sleep apnea*
- Yes
- No
Angina pectoris*
- Yes
- No
Hemophilia*
- Yes
- No
Liver disease, hepatitis*
- Yes
- No
Congenital heart disease*
- Yes
- No
Kidney problems*
- Yes
- No
Alcohol - more than one drink/day*
- Yes
- No
Artificial heart valve*
- Yes
- No
Urinary Problems*
- Yes
- No
Use of recreational drugs*
- Yes
- No
High blood pressure*
- Yes
- No
Stomach ulcers*
- Yes
- No
Use of medical marijuana*
- Yes
- No
Fainting or dizziness*
- Yes
- No
Acid reflux, heartburn*
- Yes
- No
Cold sores*
- Yes
- No
Stroke*
- Yes
- No
Diabetes*
- Yes
- No
HIV/AIDS*
- Yes
- No
Epilepsy or seizures*
- Yes
- No
Thyroid disease*
- Yes
- No
Psychiatric care*
- Yes
- No
Artificial joint replacement*
- Yes
- No
Cortisone/steroid use*
- Yes
- No
Radiation treatment*
- Yes
- No
Arthritis or osteoporosis*
- Yes
- No
Glaucoma*
- Yes
- No
Chemotherapy*
- Yes
- No
Reason for your visit
Reason for referral to our office
How long has this been a problem?
Name of family physician
Phone
Please provide any details to any YES answers
Have you been under the care of a physician in the last 5 years?*
- Yes
- No
Notes
Have you had any past hospitalizations or operations?*
- Yes
- No
Notes
Are you on any medication or have you been on medication in the past 5 years? PLEASE LIST*
- Yes
- No
Notes
Do you have any allergies to any medications? (rash, swelling, difficulty breathing or hives)*
- Yes
- No
Notes
Do you have a personal or family history of difficulties or unfavourable reaction to local or general anesthetics?*
- Yes
- No
Notes
Do you have a personal or family history of malignant hyperthermia, cholinesterase deficiency or porphyria?*
- Yes
- No
Notes
Do you have any neuromuscular problems, nervous system disorders, multiple sclerosis or muscular dystrophy?*
- Yes
- No
Notes
Do you have a problem with bleeding, easy bruising or clotting?*
- Yes
- No
Notes
Have you had any heart problems in the past?*
- Yes
- No
Notes
When you walk up stairs or walk several blocks do you get short of breath, chest pain or excessively tired?*
- Yes
- No
Notes
Do you smoke, vape, or chew tobacco? If so how much and for how many years? If you quit, when did you quit?*
- Yes
- No
Notes
Do you have a history of asthma, bronchitis, COPD or emphysema? If so have you been hospitalized for this?*
- Yes
- No
Notes
Have you ever had rheumatic or scarlet fever? If so, do you have a heart murmur?*
- Yes
- No
Notes
For women, are you or could you be pregnant?
- Yes
- No
Notes
Are you on any special diet? Is it on the advice of a physician? Any change in weight over the past year?*
- Yes
- No
Notes
Do you have any jaw joint (temporomandibular joint) problems or other jaw or jaw muscle problems?*
- Yes
- No
Notes
Is there anything special about your medical history or physical condition that you feel we should know?*
- Yes
- No
Notes
Date*
DD slash MM slash YYYY
Signature of Patient/Parent or Guardian
Relationship to patient if person completing the form is not the patient
Form contains attachment or additional info
Drop files here or

Max. file size: 300 MB.
By submitting this form you consent to our Privacy Policy.
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Our surgeons:

Dr. Darrell Gotaas
Dr. Eugene Lam
Dr. Lachlan McLean

About Us
- Our Team
Our Procedures
Patient Information
Contact
Register
Referrals

About Us
- Our Team
Our Procedures
Patient Information
Contact
Register
Referrals

Suite 100
5555 Calgary Trail NW (Clark Builders Place)
Edmonton, Alberta T6H 5P9

Email: reception@seoralsurgery.ca

Privacy Policy

Website designed by zag

About Us
- Our Team
Our Procedures
Patient Information
Contact

About Us
- Our Team
Our Procedures
Patient Information
Contact

Referrals
Register

Referrals
Register

1234 Address St. Edmonton AB T6C1B3

Info@seos.com