Welcome! In order to render the best care possible it is necessary that we get to know you a little better. Of course all of this info is confidential. We appreciate you taking the time to fill out this form. (Double Sided)

Scheduling Dental Appointments in*

Walk In Family Dentistry

PERSONAL INFORMATION

First Name*

Last Name*

Gender*

Male

Female

Other

Birth Date: (year-month-day)*

Email*

Address*

ZIP / Postal Code

City*

Province*

Mobile Phone*

Home Phone

Health carde No.

Family Doctor name

Family Doctor phone

Please write Reason for Visit Today (Examination or Emergency)

Referred By

INSURANCE INFORMATION

Name of Insured

Policy Holder Date of Birth

Insurance Company

Employer

Policy No.

Policy ID No.

MEDICAL HISTORY

1.Have you ever had a serious illness, operation, surgery, or been hospitalized? If Yes, explain*

Yes

If Yes, explain

2. Are you under the care of a physician now for any problem?*

Yes

If Yes, explain

3. Are you taking any medicines, drugs, or pills presently?*

Yes

If Yes, explain

4. Do you have any allergies? Are you allergic to any medicines or drugs?*

Yes

If Yes, explain

5. Have you ever had freezing (local anesthetic) in your mouth?*

Yes

If Yes, explain

6. Do you bleed abnormally?*

Yes

If Yes, explain

7. Do you bruise easily?*

Yes

If Yes, explain

8. Have you ever fainted?*

Yes

If Yes, explain

9. Do you have shortness of breath?*

Yes

If Yes, explain

10. Do you have any chest pains?*

Yes

If Yes, explain

11. Do your ankles ever swell?*

Yes

If Yes, explain

12. Have you gained or lost excessive weight recently?*

Yes

If Yes, explain

13. Have you ever taken cortisone or steroids?*

Yes

If Yes, explain

14. Is there any history of family disease?*

Yes

If Yes, explain

15. Do you have a night guard?*

Yes

If Yes, explain

16. Do you smoke? If Yes, How many cigarettes/day?*

Yes

If Yes, explain

17. WOMEN: Are you pregnant? If Yes, in what stage of pregnancy?*

Yes

If Yes, explain

18. Is there anything that the dentist should know regarding your Medical history that has not been mentioned?

If Yes, explain

DENTAL HISTORY

1. Have you ever had a complete dental examination with a full series of dental x-ray’s within the past 3 years?

2. How long ago was your last dental cleaning? _

3. How long ago were your x-rays taken?

4. Have you had any extractions? If Yes, did you experience prolonged bleeding after.

5. Have you ever had any of the following dental treatments? (Circle)

If Yes, explain

6. Are you aware of bad breath or a bad taste in your mouth?

7. Have you ever had a bad experience at the dentist?

8. What is your present dental problem or needs?

OFFICE PHILOSOPHY AND POLICY: (Please Read)

• In an effort to determine a treatment plan that is best for your overall dental health, we must make a careful diagnosis. This involves a thorough examination, often utilizing the minimum number of X-rays necessary for accuracy.
• We pledge to provide high quality dentistry in the most comfortable manner possible, with the best equipment, materials and up to date techniques.
• The long term success of our effort will depend on the patients' willingness to maintain their teeth and prevent any future dental problems.
• Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we require 48 hours’ notice; or a $75.00 charge may be applied. We do NOT accept cancellation through voicemail.
• Our office policy is that services are paid for at each visit as they are performed. In certain circumstances, financial arrangements for payment may be made by consulting the patient care coordinator.
• Insurance: All patients with dental insurance are responsible for payment of their own accounts. We are pleased that you have insurance to reimburse or minimize your personal expenditure and we will gladly complete any claim forms to assist you in coordinating your dental benefits. Please make certain you understand any limitations in your contract. We will gladly submit 'estimate forms, if necessary.
• All urgent dental problems will be attended to the same day, under normal circumstances. You may call our office or answering service at any time.
• A healthy dentist-patient relationship is based on mutual respect and understanding. Please feel relaxed and open to discuss with us, any aspect of your treatment or fees, at any time.

Consent Form: Collection, Use and Disclosure of Personal Information (PIPEDA)

The privacy of personal information is an important part of our daily practice in providing you with quality dental care. We are committed to collecting, using and disclosing your personal information responsibly while being as open and transparent as possible about the way we handle your personal information.

Our office is committed to:

• Only collect necessary information about you.
• We only share your information with your consent.
• The storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.
• Our privacy protocols comply with Privacy Legislation, Standards of our Regulatory Body, The Royal College of Dental Surgeons of Ontario and the law.
In this office, Dr. Vida Siar acts as the Privacy information officer. Do not hesitate to discuss our policies with Dr. Vida Siar or any member of our staff. Please be assured that every staff member is committed to ensuring that you receive the best quality dental care.

How our Office Collects, Uses and Discloses Patient’s Personal Information

Your privacy is important to us. To help you understand how we are protecting your information, we have outlined below how our office is using and disclosing your information.

The office will collect, use and disclose information about you for the following purposes:

• To deliver safe and efficient patient care.
• To identify and to ensure continuous high quality of service.
• To assess your health needs and to provide health care.
• To advise you of your treatment options.
• To enable us to contact you and to establish and maintain commutation with you.
• To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care referring dentists and / or peripheral dentists.
• To allow us to maintain contact you to distribute healthcare information and to book confirm appointments. This may include sending postcard type- reminders through the mail.
• To allow us to efficiently follow up for treatment, care and billing.
• To complete/submit predetermination and dental clams for third party adjudication and payment; to provide further information that your insurer may request to aid in the processing claims.
• To comply with legal and regulatory requirements, including the delivery of patient’s charts and records to The Royal College of Dental Surgeons of Ontario in a timely fashion, when required and records to the provisions of the Regulated Health Professionals Act.
• To comply with the agreements/ undertakings entered into the voluntary by the member with the Royal Collage of Dental surgeons of Ontario, Including the delivery and/ or review of patient’s charts and records to the college in a timely fashion or regulatory monitoring purposes
. • To permit potential purchasers, practice brokers and advisors to conduct and audit in preparation for a practice sale.
• To deliver your charts and records to the dentists insurance carrier to enable the insurance company to access liability and quantity of damage, if any;
• To prepare materials for the Health Professionals Appeal and Review Board (HPARB).
• To invoice for goods and services.
• To process credit card payments.
• To collect unpaid accounts.
• To assist this office to comply with all regulatory requirements.
• To comply with the law.
By signing this consent form, you have agree and consent to the collection, use and / or disclosure of your personal information for the purposes that are listed above. If any new purpose arises for the use and/ or disclosure of your personal information, we will seek your approval in advance. Your information may be assessed by regulatory authorities under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. 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 this information directly for your review, and for your specific consent. When unusual requests are received, we will contact you for your permission to release any information. We may also advise you if such release is inappropriate. You may withdraw your consent for use or disclosure of you personal information, and we will explain the ramifications of the decision along with following steps.

LOCAL ANESTHESIA: May cause reactions like: Bruising, Hematoma, Cardiac Stimulation, Temporary, or rarely permanent numbness of the tongue, lips, teeth, jaw and/ or facial tissue or muscle soreness.

Please verify your provided information*

I have reviewed the above information that explains how my office will use my personal information, and the steps that my office is taking to protect my information.

I know that my office has a Privacy Code, and I can ask to see the Code at any time.

I agree that walk in family dental can collect, use and disclose my personal information as set out in the privacy policy.

I give consent to walk in family dental for my Insurance Company to be contacted to help me get optimum coverage details and treatment predetermination responses sent to walk in family dental in a timely manner.

CONSENT FOR TREATMENT

This is to certify that I consent to the performing of all dental procedures agreed to be necessary and I will assume responsibility for all fees associated with all procedures.

Date

Signature*