Patient Registration Form [Final]

Patient Information
What are you registering for?

Consultation appointmentSame-day surgery and consult*
*Consultation and surgery the same day if our surgeons deem the patient a suitable candidate.
Patient Name*

First NameLast Name
Preferred Name (if different)
Address

Street Address

Street Address Line 2

CityProvince

Postal code
Cell Phone
Insert 10 digit Phone Number
Alternate Phone
Insert 10 digit Phone Number
Email
example@example.com
Date of Birth

MonthDayYear
Gender

FemaleMaleNon-binaryChooses not to disclose
Occupation
Patient Health Care Number (No Spaces or Dashes)**
*Be sure to have your health care with you on the day of your appointment.
List province if not Alberta
Emergency Contact

First NameLast Name
Emergency Contact's Phone Number
Insert 10 digit Phone Number
Referring Dentist or Doctor

First Name Last Name
Phone number of referring Dentist or Doctor
Insert 10 digit Phone Number
Purpose of Visit
Family Dentist (if different from referring Dentist)

First NameLast Name
Orthodontist (if different from referring Dentist)

First NameLast Name
Family Physician (if different from referring Doctor)

First NameLast Name
Responsible Party

Parent / Guardian / Spouse Information (Person Financially Responsible)
Name of Parent / Guardian / Spouse Information

First NameLast Name
Relationship to Patient (Parent / Guardian / Spouse)
Address (if different from Patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Insert 10 digit Phone Number
Alternate Phone
Insert 10 digit Phone Number

Primary Dental Insurance
Name of Insurance Company
Policy / Group Number
Certificate / I.D. Number
Subscriber's Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Subscriber Relationship to Patient (Parent / Guardian / Spouse)
Subscriber Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Cell Phone
Insert 10 digit Phone Number
Subscriber's Alternate Phone
Insert 10 digit Phone Number
Insurance Card Requirements

Be sure to have your insurance card with you on the day of your appointment.
Do you have secondary insurance?

YesNo

Secondary Dental Insurance
If you have Secondary insurance, please complete info for the 2nd subscriber.
Name of Secondary Insurance Company
Company Name
Policy / Group Number
Policy / Group Number
Certificate / I.D. Number
Certificate / I.D. Number
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Subscriber Relationship to Patient (Parent / Guardian / Spouse)
Relationship Description
Subscriber Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Insert 10 digit Phone Number
Alternate Phone
Insert 10 digit Phone Number

Government Coverage

*Please present your coverage card if you are eligible with the following plans.
Please Indicate Type Below (Social Assistance / Alberta Works / AISH / NIHB / First Nation / Inuit)
Type of Insurance
I.D. Number
Insurance I.D. Number
Band Name (if applicable)
Band Name
Is this a Worker's Compensation claim?

YesNo

Consent Forms

Please read the following consent forms and sign at the base of the document.

PIPA (Privacy) Consent
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and e-mail addresses (collectively referred to as “Contact Information"). Contact Information is collected and used for the following purposes:
• To open and update patient files.
• To invoice patients and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process credit card payments or to collect unpaid accounts.
• To process claims for payment or reimbursement from third-party benefit providers, insurance companies and government agencies.
• To send reminders to patients concerning the need for further dental examination or treatment.
• To send patients informational material about our dental practice.

Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient‘s behalf.

Financial information may be collected in order to make arrangements for the payment of dental services from whomever has been written as financially responsible for the account.

We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (Collectively referred to as “Medical Information"). Patients’ medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patients’ Medical information is disclosed:
• To all third party benefit providers, insurance companies and government agencies where a claim is being submitted for reimbursement or payment of all or part of the cost of dental treatment.
• To other dentists and all other health care providers, where further information and/or discussion is required.
• To other dentists and dental specialists if the patient has been referred by us to the other dentist or dental specialist for treatment.
• To other dentists and dental specialists, where those dentists have asked us to provide a second opinion.
• To other health care professionals such as physicians if the patient has been referred by us to the other health care professional for either a second opinion or treatment.
• Where we are seeking and/or providing information to the following: laboratories, radiology centres, hospitals, etc.
• To include the following when necessary, such as: videos, pictures, slides, etc, for educational purposes.
• A student and/or other dental practitioner may observe for educational purposes.
• Should any of the above information be requested, authorization is being granted to transmit electronically via e-mail or fax.

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs. We will take steps to ensure the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interests.

In addition, should you wish to grant South Calgary Oral and Maxillofacial Surgery permission to disclose and/or release any and all medical information and/or financial information on your behalf to a family member, significant other or friend, please indicate so below:

I hereby authorize South Calgary Oral and Maxillofacial Surgery permission to disclose and/or release any and all medical information and/or financial records on my behalf to (print name of family member, significant other or friend):
Full Name

By signing below, I consent to the collection, use and disclosure of my personal information as set out above.

Patient/Legal Guardian Signature
Signatory Printed Name*      Date*
Signature*
Diagnostic Imaging Consent

As part of your surgical care, a Cone Beam Computed Tomography may be required. There are certain inherent and potential risks in the use of radiation, and in this specific instance, such risks have been minimized by the use of a highly collimated x-ray beam, the latest technology in x-ray detectors and the use of lead aprons.

A CBCT scan, also known as Cone Beam Computerized Tomography, is an x‐ray technique that produces 3D images of your oral & maxillofacial regions. CBCT scans are primarily used to visualize bony structures such as your teeth and jaws; not soft tissue such as your tongue or gums. Advantages of a CBCT Scan over conventional x-rays: A conventional x‐ray of your mouth limits your surgeon to a two‐dimensional or 2D visualization, known as a Panorex. Diagnosis and treatment planning can require a more complete understanding of complex three‐dimensional or 3D anatomy. CBCT examinations provide a wealth of 3D information which may be used when planning for dental implants, surgical extractions, maxillofacial surgery as well as diagnosis and treatment of pathology related findings. The CBCT scan enhances your surgeon’s ability to see what needs to be done before treatment is initiated.

Radiation Risks: CBCT scans, like conventional x‐rays, expose you to radiation. All radiation exposure is linked with a slightly higher risk of developing cancer. But the advantages of the CBCT scan can outweigh this disadvantage. By comparison, the CBCT is only a fraction as much as an equivalent medical CT Scan. Risk is minimized by the use of a highly collimated x‐ray beam, the latest technology in X‐ray detectors and the use of lead aprons.

Pregnancy: Women who are pregnant should not undergo diagnostic imaging or radiographs due to the potential danger to the fetus. Please inform SCOMS personnel if you are pregnant, planning to become pregnant, or are unsure if you could be pregnant.

Pediatric patients: Because children are more sensitive to radiation, their exposure should be very limited. Diagnostic imaging such as radiographs and CBCT scans in children should always be performed with low-dose technique, a guideline strictly followed by SCOMS and its personnel.

Diagnosis of conditions: While parts of your anatomy beyond your mouth and jaw may be evident from the scan, this may not be your surgeon’s area of expertise. If any abnormalities, asymmetries or pathologic conditions are noted upon the CBCT scan, it may become necessary to forward the scan to an Oral and Maxillofacial Radiologist or Medical Radiologist for further diagnosis, or further imaging.

Please do not sign this form unless you have read it, understand it, and agree to accept the risks and advantages noted.

By signing below, I certify that:
-I have read the Diagnostic Imaging Consent.
-I understand the procedure to be used and accept the risks and advantages noted.
-I give my consent to have South Calgary Oral and Maxillofacial Surgery and their personnel, as they may designate, perform radiographs (X-rays) and/or CBCT scans.

Patient / Legal Guardian Signature
Signatory Printed Name* Date*
Signature*
Pandemic Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period and carriers of the virus may not show symptoms and still be contagious.

I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.

I confirm that I am not presenting any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever (adults >37.8*C pediatrics >38*C), cough, shortness of breath, difficulty breathing, sore throat and/or runny nose, loss of or change to my sense of smell and/or taste, vomiting, diarrhea.

I will notify SCOMS (via patient intake process or verbally) if I am high risk for COVID-19 ie. been diagnosed with any of the following: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over the age 65.

I confirm that I am not knowingly positive for the novel coronavirus. I also confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that if I have travelled anywhere outside of Canada in the last 14 days, that I meet the Government of Canada Quarantine Exemption Criteria.

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.

*SCOMS follows the most up to date AHS infection prevention and control standards.

By signing below, I confirm that I have read and understood the pandemic consent.


Patient / Legal Guardian Signature
Signatory Printed Name*   Date*

Signature*
Should be Empty:

	Yes	No
Are you experiencing any pain at this time?
Do you clench or grind your teeth?
Have you had any problems with local anesthetic (freezing)?
Do you have any allergies or unusual reactions to any medications or foods?

	Yes	No
Do you have high blood pressure?
Have you ever had rheumatic fever or scarlet fever?
Do you have a heart murmur?
Do you have any heart problems?
Do you have any implants in your body (heart valve, knee, hip)?
Do you have any liver disease?
Do you have any kidney disease?
Do you have diabetes?
Do you have any breathing or lung problems ( bronchitis, etc.)?
Have you had radiation treatment for cancer?
Do you suffer from osteoporosis?
Do you suffer from reflux or other gastrointestinal disease?
Do you have a history of glaucoma?
Have you ever had a bleeding problem or blood disorder?
Are you taking blood thinners (anticoagulants)?
Do you have a history of glaucoma?
Do you think you might be pregnant / Are you nursing?
Do you suffer from sleep apnea?

	Yes	No
Smoke
Vaping
Cannabis
Alcohol
Illicit drugs
IV drug abuse

Patient Information

Responsible Party

Primary Dental Insurance

Insurance Card Requirements

Secondary Dental Insurance

Government Coverage

Health History

Signature*