Patient Registration Form

We Welcome Your Online Patient Registration!

Please complete the following information as best as possible and click on submit at the end. Alternatively, if you do not wish to use the Patient Registration Form online form submission. Please download the PDF form from the link to the right. If you have any questions about this Patient Registration Form, do not hesitate to contact us directly at  (780) 532-2225 before submitting the form.

Please fill out the information below as completely as possible.

IMPORTANT: When you click submit, you will receive a successful confirmation message. If you do not see the confirmation message, you will need to check through the Patient Registration Form and complete any missing information. A confirmation e-mail will be sent to you confirming the successful submission to the Peace Periodontics Team.

    Patient Information

    * indicates required

    Insurance Information
    Do you have dental insurance? YesNo



    Health Information

    Periodontal disease may be caused by a combination of several factors and the following questions are designed to help us identify them. The success of therapy is dependent upon this. Therefore, although some of the following questions may seem unrelated to your periodontal condition, they are all associated with proper management of your oral health.


    All information provided is kept strictly confidential.


    (example: aspirin, tranquilisers, steroids, etc.)*

    Has your general health changed in the past year?Have you ever had any serious illness or major operations?Have you had abnormal bleeding associated with previous tooth extraction, surgery, or trauma?Do you have any allergies? (food, dust, drugs, fur, latex, etc.)?

    Dental anaesthetics (novocaine, etc.)AspirinPenicillin or other antibioticsCodeineBarbituates (sleeping pills)Other drugs

    Dental History



    For Women Only

    Consent (required)

    *Please ensure consent acceptance is checked. Form will not submit otherwise.

    Form Submission sent using this Patient Registration Form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use prior to submitting your referral request.

    Featured Periodontal Services

    Testimonial

    Dr Ward Piepgrass is an amazing Dentist and human being. I have had him as a dentist for 31 yrs. his work is excellent, he Has tremendous talent and is a kind gentle Person. He explains what the procedure will be, his staff are kind and courteous. I would highly recommend him!

    Anonymous from RateMDs

    I am terribly scared of dentist from past experience! Thankfully the staff and Dr. Piepgrass made me so comfortable and fixed such a big problem I was having! You gave me so much out of this visit I cannot thank them all enough!! I highly recommend this dentist!!

    Sage from Google

    Contact Us

      Working Hours

      Monday:8:00 am – 5:00 pm
      Tuesday:8:00 am – 5:00 pm
      Wednesday:8:00 am – 5:00 pm
      Thursday:8:00 am – 5:00 pm
      Friday:8:00 am – 2:00 pm
      Saturday’s, Sunday’s
      & Statutory Holidays:
      Closed

       

      Offering Solutions For Your Periodontal Issues