New Patient Form adentaloffice.com

New Patient Form - A Dental Office

Date

Patient Name (First)

Patient Name (Middle)

Patient Name (Last)

Contact Information

Address

Address Line 1

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Work Phone Extension

Health Card Number

Date of Birth

Family Status

Gender

What sex were you assigned at birth?

Male

Female

What is your current gender identity?

Male

Female

Other

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!

What pronouns do you prefer that we use when referring to you? (check all that apply)

Your Family Physician

Family Physician Name (First)

Family Physician Name (Last)

Physician's Phone Number

Emergency Contact Information

In case of emergency, We should notify:

Emergency Contact Name (First)

Emergency Contact Name (Last)

Relationship

Phone Number for Emergency Contact

Employer's Name

Occupation

Payment Information

Party responsible for payment

Self

Other

Insurance Information

Please note, patient is responsible with providing us a copy of their insurance card(s).

Primary Insurance Provider

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

Name of Insured (First)

Name of Insured (Last)

Patient's relationship to insured

Insured's Date of Birth

Age

Secondary Insurance Provider

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

Name of Insured (First)

Name of Insured (Last)

Is Insured a patient?

Yes

Patient's relationship to insured

Self

Spouse

Child

Other

Insured's Date of Birth

Age

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic(s)

Yes

Which Antibiotic(s)?

Other allergies or adverse reactions

Asprin / Advil

Codeine

Latex

Local Anaesthetics/Novocain

Other Allergies or Adverse Reactions you might have?

Do you take blood thinners?

Yes

Do you take any other medications, vitamins or supplements?

Yes

Specify the date and score of most recent INR

List any medications and dosage (including Herbal)

Have you ever had any of the following?

Please check those that apply:

Neural

Seizures/Epilepsy

Dizziness

Nervous/Mental Disorders

Stroke

Depression

Pulmonary

Asthma / COPD

Difficulty Breathing

Respiratory Problems

Tuberculosis

Neoplastic

Cancer

Growths/Tumours

Radiation/Chemo

Digestive

Acid Reflux Disease

Stomach Problems

Ulcers

Inflammatory

Stomach Problems

Rheumatism

Osteoporosis

Cardiovascular

Angina

Heart Attack

Bleeding Disorder

High/low Blood Pressure

Heart Disease

Pacemaker

Heart Murmur

Rheumatic Fever

Low Blood Pressure

Infectious

AIDS/ HIV

Hepatitis A, B, C

Venereal Disease

Immune

Hay Fever

Allergic Reaction

Other Conditions

Diabetes

Artificial Joints

Glaucoma

Sinus Problems

Liver Disease

Kidney Disease

Sleep Apnea

Organ Transplant

Thyroid problems

High Cholesterol

ADHD

Autism

Down Syndrome

Fibromyalgia

Trigeminal Neuralgia

Specify any of the above conditions

Surgery Details

Are there any conditions or diseases not listed above that you have or have had?

Yes

Please Explain

Have you ever had any complications following dental treatment?

Yes

Please Explain

Are you now under the care of a physician, regarding an ongoing medical issue?

Yes

Please Explain

Have you or anyone related to you ever had problems with local anaesthetic?

Yes

Please Explain

Do you have any health problems that need further clarification?

Yes

Please Explain

Do you smoke?

Yes

Used to

How many cigarettes a day?

When did you quit?

Do you use any recreational drugs?

Yes

Please list what kind

Do you have a prosthetic or artificial joint?

Yes

Where?

Radiation Treatment?

Yes

Where on body and when?

Do you have or have you ever had a replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?

Yes

When was your last dental visit?

When was your last have dental x-rays?

How often do you brush your teeth?

How often do you floss your teeth?

Select all that apply

Some or all of your teeth ache

Your gums bleed when you brush

You have pain when you chew

You feel you have bad breath

Please list anything else not mentioned above regarding your past dental history.

Whom may we thank for referring you to our practice ?

Google

Facebook

Instagram

Yellow Pages

Work

Newspaper

Walk-by / Business sign

Current patient of ours. Provide us with a name, so we can thank them.

Other

Please specify

Name of referrer

Consent for Services & Office Agreement

I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.
I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).
I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.
I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.
My dental insurance plan is a contract between myself and the organization providing me with the coverage.
It is my responsibility to ensure that the treatment I request is covered. However, adentaloffice.com will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. adentaloffice.com has NO knowledge of what is covered by my insurance plan. If I have a booklet, adentaloffice.com will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. adentaloffice.com will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.
adentaloffice.com also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.
adentaloffice.com will always make every attempt to see emergency cases promptly.
adentaloffice.com will accept Visa, MasterCard, debit and cash.
adentaloffice.com will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent and Awareness of Use for Email and Text

It is my request to use email/text.
Email/text is not a secure system for sending/receiving information.
Email/text conversations will be documented in my clinical record.
No Email/text either sent by myself or a staff member will be forwarded to anyone else without consent of the other party.
Any decision by either myself or a staff member to stop the use of email/texts will be respected.

Consent for Collection, Use and Disclosure of Personal Information

I agree that adentaloffice.com has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.

I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature of patient, parent or guardian

Date