New Patient Information Form

NEW PATIENT INFORMATION FORM
Do you have a fever, difficulty breathing or a cough?*

YESNO
Have you returned from travel in the last 14 days?*

YESNO
Have you been in contact with a suspected or confirmed case of COVID-19?*

YESNO
Are you experiencing pain or discomfort?*

YESNO
PERSONAL INFORMATION
Full Legal Name:*

First NameLast Name
Today's Date:*

MonthDayYear
Date
Email:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code
Date of Birth:*

MonthDayYear
Date of Birth
Telephone Number (Home):
Please enter a valid phone number.
Telephone Number (Work):
Please enter a valid phone number.
Telephone Number (Cell):
Please enter a valid phone number.
Emergency Contact:
Emergency Contact Tel. Number:
Please enter a valid phone number.
Relationship:
Name of Primary Physician:
Telephone No. of Primary Physician:
Please enter a valid phone number.
Date of Last Visit:
How did you hear about us?*
INSURANCE INFORMATION (IF APPLICABLE)
Do you have Insurance Coverage:

YesNo
Primary:
Subscriber Name:

First NameLast Name
Insurance Company:
Policy Group Number:
Division:
Certificate Number:
Relationship to Insured:
Date of Birth:

MonthDayYear
Date of Birth
Secondary:
Subscriber Name:

First NameLast Name
Insurance Company:
Policy Group Number:
Division:
Certificate Number:
Relationship to Insured:
Date of Birth:

MonthDayYear
Date of Birth
MEDICAL HISTORY AND DETAILS
Have you been hospitalized or had a major operation within the last 2 years?

YESNO
If you indicated “Yes”, please provide details:
Are you or could you be pregnant and/or breastfeeding?

YESNO
If you indicated “Yes”, please provide details:
Do you have, or have you ever had, a heart condition or tested positive for a disease that could affect your immune system? (e.g. leukemia requiring chemotherapy)

YESNO
If you indicated “Yes”, please provide details:
Please indicate which of the following you have had or have ever had:
AIDS/HIV Positive

YESNO
Alzheimer’s Disease

YESNO
Anaphylaxis

YESNO
Anemia

YESNO
Arthritis/Gout

YESNO
Artificial Heart Valve

YESNO
Artificial Joint

YESNO
Asthma

YESNO
Blood Disease

YESNO
Bruise Easily

YESNO
Cancer

YESNO
Chest Pains

YESNO
Circulation Problems

YESNO
Diabetes

YESNO
Emphysema

YESNO
Epilepsy/Seizures

YESNO
Psychiatric Disorder

YESNO
Eating Disorder

YESNO
Fainting

YESNO
Glaucoma

YESNO
Gastrointestinal Disorders

YESNO
Head or Neck Injuries

YESNO
Heart Attack/Failure

YESNO
Heart Murmur

YESNO
Heart Pacemaker

YESNO
Heart Surgery

YESNO
Hemophilia

YESNO
Hepatitis A/B/or C

YESNO
High Blood Pressure

YESNO
Infective Endocarditis

YESNO
Jaundice

YESNO
Alcohol or Drug Dependency

YESNO
Liver Disease

YESNO
Lung Disease

YESNO
Mental/Nervous Disorder

YESNO
Organ/Medical Transplant

YESNO
Prosthetic Joints

YESNO
Sickle Cell Disease

YESNO
Stroke

YESNO
Tuberculosis

YESNO
Additional comments and/or medical conditions (current or otherwise) not listed:
Are you currently taking any prescription or non-prescription medication?*

YESNO
If you indicated “Yes”, please provide details:
DENTAL VISITS AND DENTAL HISTORY
Are you nervous during dental visits or treatment?

YESNO
Have you ever had complications from past dental treatment?

YESNO
Have you ever experienced a dental operation or procedure of any kind?

YESNO
Do you bruise easily or bleed severely when cut?

YESNO
Have you ever had any teeth removed or had teeth that never developed?

YESNO
Do your gums bleed or are they painful when brushing or flossing?

YESNO
Have you ever noticed an unpleasant taste or odor in your mouth?

YESNO
Do you have problems with your jaw joint? (pain, sounds, locking, popping)

YESNO
Are any teeth sensitive to hot or cold temperatures?

YESNO
Do you chew ice, bite your nails, or have any other oral habits?

YESNO
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

YESNO
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?

YESNO
Name of Last Dentist:
Date of Last Visit:
ALLERGIES
Are you allergic to, or have you had a reaction to, the following items?
Local Anaesthetic

YESNO
If you have ever been advised against, or had a reaction to, taking any other type of medication, please list it:
Please list any allergic conditions (e.g. asthma, hay fever, food allergies, latex allergy):
CHILDREN UNDER THE AGE OF 18 ONLY:
Please list any medical conditions the child has recently had (e.g. measles, strep throat, tonsillitis etc.)
CONSENT
COLLECTION OF PERSONAL INFORMATION

Privacy of your personal information is an important part of providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We collect personal information for the following purposes and mandate:
- Only necessary information is collected about you;
- We only collect, use, and share your information with your consent;
- Storage, retention and destruction of your personal information complies with existing legislation;
- We continuously review our policies and privacy protection protocols on an ongoing, annual basis to ensure that we comply with our obligations under various provincial legislation;
- We confirm that our privacy protocols comply with provincial privacy legislation and standards of our provincial regulatory body, as amended from time to time.
This office will collect, use and disclose information about you for the following purposes, including:
- To deliver safe and efficient patient care and to identify and to ensure continuous high-quality service.
- To assess your health and dental care needs and to advise you of treatment options.
- To enable us to contact you and to establish and maintain communication with you.
- To communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists.
- To maintain communication with you to provide health care information and to book/confirm appointments.
- To allow us to efficiently follow-up for treatment, care and billing.
- To comply with legal and regulatory requirements, including the delivery of patients' charts and records to our provincial regulatory body, in a timely fashion.
- To invoice for goods and services and to process credit card payments.
- To comply with our obligations under applicable federal and provincial privacy legislation.
By signing the consent section of this Patient Consent Form below, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes included herein. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Our office will not, under any conditions, supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly for your review, and for your specific consent. I have reviewed the above information that explains how your office will use and protect my personal information. I understand that I may withdraw my consent at any time, and, should I wish to do so, I will contact the clinic to inform them of this intention. I agree that my dental clinic or dental care herein, can collect, use and disclose personal information for the purposes set out herein.
Date:*

MonthDayYear
Date
Printed Name:*
Please use your mouse or finger to sign below.*

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(Signature)
PATIENT ACKNOWLEDGEMENTS
CANCELLATION POLICY

It is the practice of our office to see all our patients on an appointment basis. We respect your time and make every effort to remain on schedule. We ask that you extend the same courtesy to us. If you are unable to keep your appointment, we request that you notify us at least 2 business days prior to your appointment. When you do so, we are able to offer your timeslot to another patient. Patients who fail to provide us with adequate notification time will be charged a missed appointment fee of $50.00.
If you have any questions or require clarification, please contact our office.
I have read and understood the Cancellation Policy as outlined herein. I agree to the terms described and assume full liability for any fees charged should I fail to abide by these short notice requirements.
Date:*

MonthDayYear
Date
Please use your mouse or finger to sign below.*

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(Signature)
ELECTRONIC CLAIM AUTHORIZATION
I understand that my claims may be submitted electronically, and I authorize the release, to my dental benefit carrier, of information contained in claims submitted electronically.
Date:*

MonthDayYear
Date
Please use your mouse or finger to sign below.*

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(Signature)
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