Patient Intake Form Step 1 of 7 14% New Patient InformationFirst Name(Required)Last Name(Required)Preferred NameGenderMaleFemaleOtherMarital StatusOccupationBirth Date(Required) Cell Phone(Required)Home PhoneWork PhoneEmail Address(Required) What is the most convenient way to contact you?(If Patient is a Child) Name of parent or guardianContact NumberAre other family members patients here?How did you find out about our office?Name of previous DentistClinic Address:Clinic Phone Number Patient AddressAddress(Required)CityProvinceAlbertaBritish ColumbiaSaskatchewanManitobaOntarioQuebecNewfoundlandNew BrunswickNovia ScotiaPEINWTNunavutYukonPostal Code(Required) Emergency and MD In case of emergency, please contact:Full NameRelationshipPhone NumberFamily DoctorAddressPhone Number Insurance InformationPrimary Insurance CompanyPolicyIDPolicy HolderDate of Birth Relationship to ClientEmployerDo you have more than one insurance policy? Yes No Secondary Insurance CompanyPolicyIDPolicy HolderDate of Birth Relationship to ClientEmployerPlease be advised that dental insurance or benefits is a contract between you, your employer and your insurance provider and any available benefits are determined by your individual policy. Under the Privacy Act, the majority of insurance providers will not provide our office with specific details regarding your coverage. We cannot influence how much of our fees your insurance will cover. Our objective as dental health care providers is to diagnose and recommend treatment according to each patient's particular needs. We do not know if your insurance will cover the treatment we propose, as this is only outlined in your policy handbook. In you need assistance with the handbook, we can help. Patient Dental & Medical HistoryAre you currently being treated for any medical condition, or have you been treated within the past year?(Required) Yes No Please explain what you have been treated with:When was your last medical checkup? Has there been any change in you general health in the past year?(Required) Yes No Please explain the changes to your general health:Are you taking any medication(s), non-prescription drugs, or herbal supplements of any kind??(Required) Yes No Please provide details of all medications here...Do you have any allergies to medications, latex/rubber prodcuts, other (e.g. hay fever, foods, metals, etc.)?(Required) Yes No Please List all allergies details.Do you have a prosthetic or artificial joint?(Required) Yes No When was the surgery performed?Have you ever been advised to take premedication before dental treatment?(Required) Yes No Have you ever been diagnosed with cancer?(Required) Yes No Do you have a bleeding problem or bleeding disorder?(Required) Yes No Do you take baby aspirin or other blood thinners on a regular basis?(Required) Yes No Have you ever had a serious illness or operation?(Required) Yes No Do you snore?(Required) Yes No Have you ever had any of the following? (Please check all the applicable boxes) Chest Pain Angina pacemaker arthritis Malignant Hyperthermia Heart Attack Bypass Stomach Ulcers Severe Headaches Blood Pressure Problems Tuberculosis Inflammatory Bowel Disease Psychiatric Therapy Asthma Thyroid Disease Eating Disorder Rheumatic Fever Steroid Therapy Kidney Disease Seizures (epilepsy) Mitral Valve Prolapse Diabetes Shortness of Breath Liver Disease Drug / Alcohol Dependency Heart Surgery Cancer Osteoporosis Medication Sexually Transmitted Disease Congenital Heart Defect Stroke (Bone Strengtheners) Autoimmune Disease Lung Disease Are there any conditions or diseases not listed above that you have or have had?(Required) Yes No Please List all other ConditionsAre there any diseases or medical problems that run in your family?(Required) Yes No Please List all other ConditionsDo you smoke or chew tobacco products?(Required) Yes No Please detail how much tobacco you consume per day?Women OnlyAre you pregnant/breastfeeding? Yes No Patient Dental HistoryReason for Last Dentist Visit?Date of Last Dental Visit Date of Last X-rays taken Have you seen a dentist regularly? Yes No Bad taste or bad breath? Yes No Gums bleed when you brush or floss? Yes No Have you had any trauma to your jaws or face? Yes No Do you have sore teeth? Yes No Are you nervous during dental treatment? Yes No Consent:(Required)I hereby authorize the dental personnel to perform services for the prevention and treatment of dental disease using the procedures and medications required and assume responsibility for the fees associated with these procedures. I accept Signature (of Patient / Parent / Guardian)(Required)Your NameYour NameYour NameYour NameDate Financial Responsibility AgreementPlease take time to familiarize yourself with our office financial procedures and policies You dental insurance is a contract between you and your insurance company. We cannot guarantee payment or coverage of your claim. Insurance policies vary greatly. Therefore, owing to the complexity of Insurance contacts, you are fully responsible for knowing your own insurance plan. Treatment is recommended based on what you need, not on what you are covered for. As a courtesy, we will prepare and submit claims on your behalf. Full payment will be required if your insurance does not allow direct billing. Balances are to be paid in full at each appointment, unless written financial arrangements are made in advance of your treatment. Please discuss payment options and fees with our staff, and they would be pleased to work with you to make the required arrangements. We require a 50% deposit for major dental treatment (crowns, bridges, implants, removable appliances). If we have a valid preauthorization of benefits from your insurance provider, we will only require a deposit of the amount not covered. Any remaining balances are due on the day of service is complete. For your convenience, we accept the following forms of payment: cash, Visa, MasterCard, direct payment (Interac) or American Express. Personal cheques are not accepted. Appointment Policy As a courtesy, appointments will be confirmed by an automated service via email, text or phone. Please ensure that you respond to this service to confirm your appointment time. Cancellations must be made directly to our office at 780-363-0333. We respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance. Failure to cancel a reserved appointment may result in charge to your account.Payment Policy As a courtesy, we will direct bill to your insurance. Please note that payment is expected at each appointment as determined by your insurance plan or lack thereof. A credit card number will be kept on file for any balances not covered by your plan. Should you choose to decline to provide us with the information, we will assume non assignment for your dental plan.Your Financial Consent(Required)The patient/guardian agrees that he/she is fully responsible for payment of procedures preformed in this office. including any treatment deemed not a covered benefit by any dental insurance the patient may have. I certify I have read and understand the above. I accept Full Name:(Required)Signature(Required)Your NameYour NameYour NameYour NameDate Personal Information Consent FormWe are committed to protecting the privacy of our patients' information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal informaiton that we collect, use and disclose. In addition to the circumstances described in the form, we also collect, use and disclose personal information when permitted or required by law. Contact information is collected and used for the following purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts. To process claims for payment or reimbursement from third-party health benefit providers and Insurance Companies. To send reminders to patients concerning the need for further dental examination or treatment. To send patients informational material about our dental practice. Medical and Dental Information may also be disclosed: To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion. To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment. Dental information may include x-rays, cast models, pictures and/or videos. These will be kept as a record of care and may be used for educational purposes in study club meetings. lectures, seminars, and professional publications (journals, magazines). If any of these are used in any publication or as part of a demonstration, the patients' name and other identifying information will remain confidential. If we are ever considering selling all of part of our dental practice, qualified potential purchasers may be guaranteed access as part of the due diligence process to verify information to the potential sale. If this occurs, we will take steps tp ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College which my inspect our records and interview our staff as part of its regulatory activities. Consent Agreement(Required)I consent to the collection, use and disclosure of my personal information as set out above. I accept Name (patient / legal guardian)Signature(Required)Your NameYour NameYour NameYour NameDate
