New Patient Form - newtonbrookdentistry

FULL NEW PATIENT INFORMATION FORMS (4 IN 1)

Patient Information Details:

Today's Date:(Required)

Patient is:(Required)

Adult

Child (under 18)

Title:(Required)

Name:(Required)

First Middle Last

Patient’s preferred name:

Date of birth:(Required)

Age:

Gender

Male

Female

Other

Marital Status

Single

Married

Common-Law

Complete Mailing Address

Patient's Primary Residence:(Required)

Address and Street Name Apartment #/ Unit # City Province Postal Code

PATIENT TELEPHONE & EMAIL CONTACT INFORMATION

Cellular phone:(Required)

Home phone:

Preferred Contact(Required)

Cellular phone

Home phone

Email Address (Please provide your email address for the purpose of communication and appointment reminders).(Required)

Emergency Contact Name:

Relationship to patient?

Emergency contact cellular phone:

If you are a new patient, how did you hear about our office?

Social media

Google

My Physician

A staff member of the office

I Live In the neighborhood

Other

If you heard about our office through another source not mentioned above, please list details below:

DENTAL INSURANCE SECTION

Do you have Dental Insurance Coverage?(Required)

YES- I HAVE ONE INSURANCE

YES- I HAVE 2 INSURANCES! Please provide information after the 1st insurance information is filled.

1st Dental Insurance:

Policy holder’s full name:

Name of the Insurance Company, if known:

My Relationship to the Subscriber (policy Holder):

self

spouse

common-law

dependent

child

Policy Holder’s Date of Birth:

Policy number/ Group number/ Plan contract number :

Certificate number/ Identification number:

2nd Dental Insurance (if applicable):- Skip to the next section, CURRENT MEDICAL, if you do not have a 2nd dental insurance

Policy holder’s full name:

Name of the Insurance Company, if known:

My Relationship to the Subscriber (policy Holder):

self

spouse

common-law

dependent

child

Policy Holder’s Date of Birth:

Policy number/ Group number/ Plan contract number: :

Certificate number/ Patient Identification number :

If you have a picture of the insurance card or a screenshot of the insurance information, please attach here:

Max. file size: 1 MB.

CURRENT MEDICAL:

Do you have a Family Doctor?(Required)

yes

I only go to a walk in clinic if needed

Name of Family Physician:

Phone number of Physician:

Have you had a physical exam with your Medical doctor in the past 2 years?(Required)

Yes, see below:

If you answered yes to the above question, if you know the approximate month and/or year, please list:

Do you consider yourself currently in good health?(Required)

Yes

Not sure

Are you currently under a specialist's care or have you been under a specialist's care in the past 2 years?(Required)

Yes

Please provide details below if the above answer is yes:

Are you taking any Medications (include any vitamins or supplements)?(Required)

Yes- please list all below if the answer is yes:

Medication list:

(Please list all current medications you are taking including vitamins or supplements. Make sure to include the exact medication name, dosage, and what it is taken for)

If applicable, please include a list from your pharmacy attached below:

Max. file size: 1 MB.

Do you have any type of allergy that you know of? Please list every allergy from all groups including but not limited to environmental, foods, medications, latex rubber etc.(Required)

Yes (please explain below)

MEDICAL HISTORY:

Please check YES, NO or when prompted, MAYBE/NOT SURE/ UNSURE. To unclick a single box, click the box again and it will unclick.

Do you have any existing and/or current medical conditions? Recent Surgeries that you feel we should be made aware of?(Required)

Yes- please list all below if the answer is yes:

Medical conditions/ Recent surgeries/Important Health Information if applicable:

Do you have any conditions or therapies that could affect your immune system (example, Leukemia, Aids, HIV infection, radiotherapy, chemotherapy) ?(Required)

Yes

Not sure/ maybe

If the answer is yes, please explain the details below:

Do you bruise easily, bleed excessively, have a bleeding disorder or do you ever experience problems with healing?(Required)

Not sure/maybe

Yes- if the answer is yes, please list details below

Details of healing, bleeding or bruising? Are you taking any blood thinners?

Have you ever had a peculiar or adverse reaction to any medicines or injections?(Required)

Yes

Unsure

Have you been told that you need to pre-medicate with antibiotics prior to your dental visit?(Required)

Yes

Unsure

If the answer is "Yes" or even "Unsure", please list details below:

Are you on Osteoporosis medications (i.e. Fosamax, Actonel)? Have you been told you have Osteoporosis?(Required)

I have been told I have borderline Osteoporosis

I have been told I have a bone density issue

YES- I have osteoporosis but I AM NOT on medications

YES- I have osteoporosis AND I AM taking medications for it

Have you ever experienced or currently have the following?

Please check all applicable boxes: If you checked any of the choices below that you feel should be explained in detail, please use the box at the end.(Required)

Do you have any Mental Health disorders (i.e. severe depression, anxiety, compulsive behaviour, Bipolar disorder, schizophrenia)?(Required)

YES- if the answer is yes to any, please explain briefly below

UNSURE

If the answer above is YES in the "Mental Health section" please explain the details below:

Do you identify as a patient with a disability? If yes please explain:(Required)

MAYBE

YES

If the answer above in the "disability section" is YES or MAYBE, please explain the details below:

Drug, alcohol, cannabis use or dependency? Smoke or chew tobacco products?(Required)

OCCASIONALLY-see below

YES-see below

If the answer above is YES or even OCCASIONALLY, please explain the details below:

Women only section:

Are you pregnant?

YES

Are you taking birth control pills?

YES

Are you nursing?

YES

Are you taking fertility drugs?

YES

Do you wish to speak privately with the doctor about any problem or any condition not mentioned here?(Required)

Yes

Acknowledgement:(Required)

I have read, understood and completed the PATIENT INFORMATION AND MEDICAL BACKGROUND listed above and I have disclosed all pertinent medical information and history so that the Dental office can provide the proper care needed.

COMPREHENSIVE PATIENT CURRENT DENTAL TREATMENT & HISTORY FORM

If you are a new patient, when was your last dental check-up/ hygiene visit? (If you cannot recall the exact date or year, please approximate in months or years).

*THE ABOVE QUESTION IS FOR NEW PATIENTS ONLY

If a new patient, what is name of your previous dentist or dental office if known?

*THE ABOVE QUESTION IS FOR NEW PATIENTS ONLY

PAST AND PRESENT PATIENT DENTAL HISTORY FOR NEW AND EXISTING PATIENTS:

CURRENT DENTAL CONDITIONS OR PROBLEMS:(Required)

CURRENT DENTAL CONDITIONS OR PROBLEMS EXPLAINED IF APPLICABLE:

Are any teeth sensitive to:(Required)

sweet

hot

cold

pressure

biting

NO, MY TEETH ARE NOT SENSITIVE TO TEMPERATURE, TO PRESSURE, WHEN BITING OR WHEN EATING SOMETHING SWEET

ORAL HYGIENE:

How often do you floss your teeth?(Required)

after every meal

before bed

in the morning

Morning and night

once a day

hardly ever

never

How often do you brush your teeth?(Required)

after every meal

before bed

In the morning

Morning and night

once a day

hardly ever

never

DENTAL AIDS:(Required)

Do you use any fluoride/mouth rinses?

Do you use Dental aids such as proxy brushes, water flossers, dental picks etc.?

Do you wear a night guard?

NO, I DO NOT USE ANY OF THE ABOVE MENTIONED DENTAL AIDS

PAST DENTAL TREATMENT AND HISTORY:

Are you currently undergoing/ using/ or had any of the following apply?(Required)

Is there anything you would like to expand upon if you checked any of the above boxes in the PAST OR CURRENT TREATMENT SECTION?(Required)

YES, PLEASE SEE BELOW

HABITS

Do you clench or grind your teeth while asleep?(Required)

Yes

NOT SURE

Do you breathe through your mouth while awake or asleep?(Required)

Yes

NOT SURE

Do you bite your lips or cheeks regularly?(Required)

Yes

NOT SURE

YOUR OPINION MATTERS:

Are you happy with the appearance of your teeth?(Required)

Yes

Somewhat

What would you like to change about your teeth if you could?

Acknowledgement:(Required)

I have read, understood and completed out the COMPREHENSIVE PATIENT DENTAL HISTORY FORM listed above.

Our Office Policies

Cancellation:
The appointments are reserved time for you only. A minimum notice of two business days is required to avoid possible cancellation fees.

Payment:
Full payment is required at the time of each appointment. We accept cash, debit, VISA and MasterCard. HST is not charged. If you have any insurance benefits, they will only be assigned to you. You will pay us in full and we will send your insurance on your behalf electronically or manually in some cases.

Insurances:
Co-payment is required at the time of each appointment as well as any deductibles or fee guide differences that may arise. As everyone’s insurance details are unique it is not possible for us to be accountable for knowing all of the details pertaining to your specific plans coverage. As a courtesy, we will be more than happy to assist you with the processing of your dental claims, either electronically or manually on your behalf. We will not waive any insurance fees under any circumstances.

Privacy:
According to the Privacy Policy Act (PIPEDA), Dr. Safari & Associates is to withhold all patient information and acknowledge it as strictly confidential. Patient authorizations/signatures are required prior to the release of any information to a third party other than a collection agency.

Acknowledgement:(Required)

I have read and understood the OFFICE POLICIES listed above.

PATIENT PRIVACY CONSENT FORM

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

In this office, Dr. Mark Safari, acts as the Privacy Information Officer. All staff members who come in contact with your personal 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.

Attached to this consent form, we have outlined what our office is doing to ensure that:

All the necessary information is collected about you;
We only share information with your consent;
Storage, retention and destruction of your personal information compiles 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.

Do not hesitate to discuss our policies with me or any other member of our office staff.

Please be assured that every staff member in our office is committed to ensuring that you receive the best quality dental care.

Acknowledgment:(Required)

I have read and understood the PATIENT PRIVACY CONSENT FORM listed above.

General Consent statement and attestation

I certify that I have read, understood, and accurately completed the personal, medical, dental histories, as well as our office policies and privacy statement to the best of my knowledge, and have not knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding any medical and dental histories.I attest that the above medical information is true and completed to the best of my ability. I understand that by disclosing all of my medical information to my dentist or dental hygienist, that it is in my best interest to do so medically. As may be required, I consent to my physician being contacted regarding any specific medical question. I authorize the dentist to perform necessary diagnostic procedures and treatment, including general or local anesthetic, as required, to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive. I know that your office has a privacy code, and I can ask to see the code at any time. I agree that your office can collect, use and disclose personal information about me as set out in your office privacy policy.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

Patient Name(Required)

First Last

Signature(Required)

Date(Required)