If you have previously been a patient in our office, please inform the receptionist BEFORE completing this form.
(Consultation and surgery the same day if our surgeons deem the patient a suitable candidate)
Parent / Guardian / Spouse Information (Person Financially Responsible)
If you have dual insurance, please complete info for the 2nd subscriber.
*please present your coverage card if you are eligible with the following plans.
Confidential Health Questionnaire
*For women using oral contraceptives, if taking oral antibiotics you will need another form of birth control for one complete cycle.
If yes, has your physician recommended that you receive preventative antibiotics before dental work?Yes No
Have you been on Bisphosphonate medication in the past (for osteoporosis or bone disorder)?Yes No
Have you had any previous serious illnesses (please list)?Yes No
Have you ever had a general anesthetic or previous surgeries (please list)?Yes No
Have you or any member of your family ever had a bad reaction to general anesthetic?Yes No
To the best of my knowledge, the above information is correct.Patient’s Signature / Legal Guardian* Date*
South Calgary Oral and Maxillofacial SurgeryWe 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 centers, 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.-I hereby authorize South Calgary Oral and Maxillofacial Surgery permission to release any and all medical information and/or financial records on my behalf to:Print name of family member, significant other, friend - leave blank if n/aFirst Name Last Name 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.As part of your surgical care, radiographs may be required. There are certain inherent and potential risks in the use of radiation, and in some instances, such risks have been minimized by the use of a highly collinated x-ray beam, the latest technology in x-ray detectors and the use of lead aprons.I consent to the collection, use and disclosure of my personal information as set out above.Patient NameFirst Name* Last Name* Patient’s Signature / Legal GuardianPatient’s Signature/ Legal Guardian* Date*
Consent for Diagnostic Imaging
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.I certify that I have read the above statement.Yes No* I understand the procedure to be used including its benefits and risks.Yes No* I therefore give my consent to have South Calgary Oral and Maxillofacial Surgery, and their personnel as they may designate, perform radiograph(s) (X rays) and/or CBCT scan(s).Yes No* Patient NameFirst Name* Last Name* Patient’s Signature / Legal GuardianPatient’s Signature / Legal Guardian* Date*
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.Patient NameFirst Name* Last Name* Patient’s Signature / Legal GuardianPatient’s Signature / Legal Guardian* Date*