JENSEN LAKES DENTAL
  • 215 – 840 St. Albert Trail St. Albert, AB T8N 7V2
  • (780) 347-8080
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  • 215 – 840 St. Albert Trail St. Albert, AB T8N 7V2
  • (780) 347-8080 Request Appointment

Dental History Form


Patient Dental History

I have routinely seen my dentist every

How would you rate the condition of your mouth? *

Gum and Bone

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Tooth Structure

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Bit and Jaw Joint

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Smile Characteristics

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Medical History

Do you or have you ever had hospitalization for illness or injury?

Do you or have you ever had an allergic or bad reaction to any of the following:

Please select all of the following that you have or have ever had:

Please select any of the following that apply to you:

Please advise the office in the future of any change(s) in your medical or dental history as well as medications you may be taking.

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Hours of Operation

  • Monday: CLOSED
  • Tuesday: 9:00am – 5:00pm
  • Wednesday: 9:00am – 5:00pm
  • Thursday: 9:00am – 5:00pm
  • Friday: 9:00am – 5:00pm
  • Saturday: 9:00am – 4:00pm
  • Sunday: CLOSED

Contact Us

(780) 347-8080

info@jensenlakesdental.com

215 – 840 St. Albert Trail St.
Albert, AB T8N 7V2

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