Patient Form

The following information is required to provide you with the best dental care. All information that you provide is kept strictly confidential. If you do not understand a question. please contact our office for clarification.

On a scale of 1 to 10 (1 not nervous, 10 very nervous). Please indicate how nervous you feel about dental treatment.

For Women only

I give consent for clinical images (photographs and x-rays) to be taken of me, or of my child, or of a person for whom I am a legal guardian. I understand clinic images form part of my dental record. I understand that duplicates may be sent to the referring dentist/physician, as part of my treatment. At times, additional consolation/interpretation of the images may be required as part of my treatment. In such circumstances, Dr. Tom Wierzbicki will be required to send off the images, and relevant demographic and medical information to a third party health care provider (e.g. radiologist) for consultation. The images may be transferred by hard copy (e.g. CD) sent by mail, or electronic submission over the internet.

Furthermore, I understand that the clinical images, with my consent, may be used for the purposes of dental/medical training, research, teaching, publication in dental/medical textbooks or journals, or used for marketing of the clinic. I understand that if used for these purposes, the images will not contain any identifying information such as my name, but that it may still be possible that someone recognize me.

I acknowledge that I will not receive compensation for the use of the clinical images.

I understand that I have the right to withdraw consent at any time by written request to Dr. Tom Wierzbicki or West Calgary Periodontics staff.

I understand that refusal to consent to the use of clinical images will in no way affect the dental care I receive.

Please check Yes or No below to show type of consent given: