Willow West Patient Registration Form

Confidential Patient Information

To help us meet all your dental healthcare needs we will need the following information. All information will be strictly confidential.
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
E-mail:*
Birth Date*

MonthDayYear
Sex:

MaleFemale
Marital Status:*
How did you hear about us ?*
Work Information
Employer:

First NameLast Name
Employer:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone Number:

Area CodePhone Number
Occupation:*
Dental Benefits Information/Policy Holder
Do you have dental insurance?*

YesNo
If you have dental benefits, and wish us to accept assignment on most services, the section below needs to be filled out accurately. Please note that you are responsible for any balances NOT covered by your insurance:
Name of Insurance Policy Holder:*

First NameLast Name
Birth Date:*

MonthDayYear
Policy Holder Sex (M/F)*

MaleFemale
Policy Holder Contact Phone Number*

Area CodePhone Number
Policy Holder Employer*
Insurance Company Name*
Policy Number:*
What's the Certificate/Subscriber ID?*
In case of Emergency
Contact:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship:*
Current Medical Condition

To serve you properly we will need the following information. All information will be strictly confidential.
Family Doctor Name?*
Doctor’s Phone number? (if available)

Area CodePhone Number
When was your Last Medical Check up?*

MonthDayYear
Have you ever been hospitalized or had a serious illness?*

YesNo
If Yes, Please Explain why you been hospitalized or what a serious illness you had?
Are you being treated for any medical condition at the present time or have you been treated within the past year?*

YesNo
If Yes, Which medical condition at the present time or have you been treated within the past year?
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNo
If Yes, Please list any medications, non-prescription drugs or herbal supplements of any kind?
Women: Are you pregnant/ or Breastfeeding?

YesNo
Medical History

You will be asked few questions about your Medical History
Nervous System: Indicate which of the following you have had, or have at present.

HeadachesConvulsions/EpilepsyDizziness/FaintingPsychiatric TreatmentTrigeminal Neuralgia
Endocrine: Indicate which of the following you have had, or have at present.

DiabetesHypoglycemiaThyroid Condition/Goiter
Bone/Muscles: Indicate which of the following you have had, or have at present.

Arthritis/ RheumatismArtificial joints/LimbsOsteoporosisNeck Ache
Allergies: Indicate which of the following you have had, or have at present.

Local AnestheticsLatex SensitivityPenicillinAspirin or CodeineSulfa Drugs
Respiratory: Indicate which of the following you have had, or have at present.

Asthma/ Hay FeverSinus ProblemsDifficultly breathing while laying downCOPD / Lung Disease
Heart / Blood Vessels: Indicate which of the following you have had, or have at present.

Rheumatic FeverHeart MurmurChest Pain/DiscomfortHeart Attack /StrokeHigh Blood PressureShortness of BreathMitral Valve ProlapseArtificial Heart ValvePacemakerHeart Surgery
Blood: Indicate which of the following you have had, or have at present.

Bruise EasilyAnemiaBlood TransfusionBleeding DisorderExcessive Bleeding/ Long Healing
Digestive System: Indicate which of the following you have had, or have at present.

HepatitisLiver disease/JaundiceUlcersKidney Trouble
Immune System: Indicate which of the following you have had, or have at present.

Radiation/ChemotherapyAIDS/HIVCancer
Are there any diseases or medical problems that run in your family ?
Eg. Diabetes, Cancer or heart disease.
Do you use tobacco in any form?*

YesNo
If Yes, How much do you use tobacco per day?
Dental Condition
When was your last dental visit?*

MonthDayYear
When was your last dental cleaning?*

MonthDayYear
When did you last have dental x – rays ?*

MonthDayYear
How often do you use dental floss?*
How often do you brush your teeth?*
Have you ever had local anaesthetic (freezing)?*

YesNo
If Yes, Were there any complications with anaesthetic (freezing)?
Dental Condition (Indicate which of the following you have had, or have at present)

Bleeding, Soft GumsUnpleasant Taste/Bad BreathBlisters / Lumps in MouthOrtho Treatment (Braces)Clicking/Popping JawExperience any accidents / blows to your jawTeeth Sensitivity (hot & cold)Facial PainDifficulty Chewing/Swallowingfood pack or catch between your teethClenching or GrindingShifting in teethYellow Teeth
Are you satisfied with your teeth/smile? specify.
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the dentist of any change in my health or medication.
Patient/Guardian Signature*

Clear
Date:*

MonthDayYear
Financial Policy
Our goal is to provide our patients with the highest level of dental care and transparency. We want to ensure that you understand exactly what is being done, the costs associated, benefits, and the risks. Once you agree to treatment, and book an appointment, you will be asked to pay the fee for the treatment rendered at the time of service.
We can help you with sending an estimate prior to your appointment. However, with many benefit providers these days, we do not receive the breakdown of coverage, as the responses go directly to you. We cannot be held accountable for what your benefits cover and do not cover.

For ongoing treatment, we will submit the estimates and claims on your behalf and help you with any requests your provider has. Please note there are hundreds of benefit plans, and they are a reflection of what your employer has chosen to sign you up for. If you contact your HR department, then can provide you with an actual booklet or link that you can bring to your appointment, which assists us in understanding your coverage.
You will be asked to pay the fee at the time of service. You are responsible for the payment of all the fees for dental care rendered at Willow West Dental. For your convenience if you would like we can contact your dental benefit provider so that you know what is covered. Since there is a possibility that the information given over the phone can be inaccurate, we cannot be accountable for what your benefits cover. We will submit the claim on your behalf and help you with any request your benefit provider might have.
How would you like to pay for your visit ?*

ChequeCashDebitCredit Card
APPOINTMENT POLICY

A scheduled appointment means the dentist and their team have reserved a time specifically for you, and no other patients are seen at that time. If for some reason you know you cannot make your appointment, we require a 48 business hour notice (this does not include weekends) so we can give your scheduled time to other patients. Patients who do not follow this policy may be charged a $50/- fee and/or may no longer remain patients of this practice.
Privacy of your personal health information is an important part of our office, providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Please visit our full privacy policy statement available in our website https://willowwestdental.com/privacy-policy
Patient/Guardian Signature*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Confidential Patient Information

Work Information

Dental Benefits Information/Policy Holder

In case of Emergency

Current Medical Condition

Medical History

Dental Condition

Financial Policy