NEW PATIENT FORM

Welcome. In an effort to serve you better, Grant Dental Centre would ask that you complete the following form. We will be glad to assist you.

PATIENT INFORMATION

A PARENT OR GUARDIAN WILL BE RESPONSIBLE FOR DECISIONS ON MY TREATMENT

Yes

(Mr / Mrs / Ms / Other/Specify)

NAME:

First

Middle

Last

ADDRESS:

Apt.

Street

City

Prov.

Postal Code

Date of Birth:

Home Telephone:

Work Telephone:

Cell:

E-Mail Address:

Preferred Method of Communication:

Text message

Employer:

Family Doctor:

Phone:

Cell

Home

Work

E-mail

Emergency Contact & Phone:

Phone:

Referred By:

FINANCIAL INFORMATION

Method of Payment:

Person Responsible for Financial Matters:

Self

Spouse

Parent/guardian

Other

ADDRESS:

Apt.

Street

City

Prov.

Postal Code

Date of Birth:

Home Telephone:

Work Telephone:

PRIMARY INSURANCE

Subscriber:

Date of Birth:

Insurance Company:

Certificate/ID:

Policy /Plan/Group:

Yearly Limit:

% COVERAGE

Basic

Major

Ortho

SECONDARY INSURANCE

Subscriber:

Date of Birth:

Insurance Company:

Certificate/ID:

Policy /Plan/Group:

Yearly Limit:

% COVERAGE

Basic

Major

Ortho

MEDICAL HISTORY (THIS INFORMATION WILL REMAIN CONFIDENTIAL)

MEDICAL HISTORY

Date

Are you presently under the care of a physician? If so explain.

YES

Have you had surgery in the last 2 yrs? Explain.

YES

LIST MEDICATIONS OR DRUGS YOU ARE TAKING AT THIS TIME.

Drug

Reason

Drug

Reason

Drug

Reason

Drug Allergies or any adverse effect to any of the following:

Other allergies (latex or environmental etc.)? Which?

YES

Have you ever been warned against using any other medications? Which?

YES

Have you ever taken prolonged medical or non-medical drugs? Which?

YES

DO YOU BRUISE EASILY OR HAVE PROLONGED BLEEDING?

Do you smoke? How much per day?

YES

HAVE YOU EVER FAINTED, OR HAD SHORTNESS OF BREATH OR CHEST PAIN?

FOR WOMEN,

Are you pregnant?

YES

MEDICAL HISTORY

Using birth control?

YES

Reached menopause?

YES

Clear

Not Clear (please choose from list)

Other

FOR CHILDREN, HAVE YOU RECENTLY (WITHIN 2-3 WEEKS) HAD ANY OF THE FOLLOWING (APPROXIMATE DATE)?

Chickenpox

Measles

Mumps

Strep throat

Tonsillitis

None

DENTAL HISTORY

HAVE YOU EVER HAD LOCAL ANESTHETIC (FREEZING)?

Any complications?

YES

(If yes, please specify)

GENERAL RELEASE

I, THE UNDERSIGNED, UNDERSTAND THAT THE INFORMATION CONTAINED IN THE MEDICAL AND DENTAL HISTORY IS IMPORTANT TO MY TREATMENT AND GIVE PERMISSION FOR THE COLLECTION OF THIS PERSONAL INFORMATION. I WILL INFORM THE DENTAL OFFICE OF ANY UPDATED INFORMATION REGARDING MY HEALTH OR OTHER PERSONAL INFORMATION IN THE FUTURE. I CERTIFY THAT ALL OF THE INFORMATION I HAVE COMPLETED IS CORRECT AND THAT I HAVE NOT KNOWINGLY OMITTED DATA. I AUTHORIZE THIS DENTAL OFFICE TO PERFORM DIAGNOSTIC PROCEDURES AS MAY BE REQUIRED TO DETERMINE THE NECESSARY TREATMENT. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO PAY FOR DENTAL TREATMENT FOR BOTH MYSELF AND MY DEPENDENTS. I ASSUME ALL RESPONSIBILITY FOR FEES ASSOCIATED WITH MY DENTAL TREATMENT OR DENTAL DIAGNOSTIC PROCEDURES. I ALSO GIVE PERMISSION FOR THIS DENTAL OFFICE TO MAINTAIN COMMUNICATION WITH ME VIA PHONE OR MAIL FOR FOLLOW-UP APPOINTMENTS AND BILLING, THE BOOKING AND CONFIRMATION OF APPOINTMENTS AND THE DISTRIBUTION OF DENTAL HEALTH INFORMATION. THIS DENTAL OFFICE MAY COMMUNICATE WITH OTHER TREATING DENTISTS AND HEALTHCARE PROVIDERS INCLUDING PHYSICIANS, SPECIALISTS AND/OR REFERRING DENTISTS. I GIVE PERMISSION FOR DENTAL CLAIMS TO BE SUBMITTED TO INSURANCE COMPANIES FOR REVIEW AND PAYMENT UNDER MY INSURANCE PLANS AND ALSO TO PROCESS PAYMENTS FOR DENTAL CARE AND OTHER PURCHASES MADE AT THIS OFFICE.

PATIENT PRIVACY CONSENT

I HAVE REVIEWED THE PRIVACY CONSENT FORM PROVIDED THAT OUTLINES HOW THE OFFICE WILL USE MY PERSONAL INFORMATION AND THE STEPS THE OFFICE IS TAKING TO PROTECT MY INFORMATION. I AGREE THAT GRANT DENTAL CENTRE CAN COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS SET OUT IN THE OFFICE'S PRIVACY POLICIES.

Signature

Self

Parent/guardian

Print Name

Date

PATIENT PRIVACY CONSENT FORM

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

PRIVACY OF YOUR PERSONAL INFORMATION IS AN IMPORTANT ASPECT OF OUR OFFICE IN PROVIDING YOU WITH QUALITY 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.

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. STAFF ARE TRAINED IN THE APPROPRIATE USES AND PROTECTION OF YOUR INFORMATION.

ACKNOWLEDGMENT OF PRIVACY PRACTICES

BY SUBMITTING THIS FORM, I HEREBY ACKNOWLEDGE AND CONFIRM THAT:

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY AND RELATED STATEMENTS SET FORTH ABOVE.
I CONSENT TO THE COLLECTION, USE, AND DISCLOSURE OF MY PERSONAL INFORMATION FOR THE PURPOSES DESCRIBED, IN ACCORDANCE WITH APPLICABLE LEGISLATION, INCLUDING THE PERSONAL INFORMATION PROTECTION AND ELECTRONIC DOCUMENTS ACT (PIPEDA).
I UNDERSTAND THAT MY PERSONAL INFORMATION MAY BE ACCESSED BY REGULATORY AUTHORITIES UNDER THE TERMS OF PIPEDA AND FOR THE PURPOSE OF DEFENDING A LEGAL ISSUE.
I ACKNOWLEDGE THAT THIS OFFICE WILL NOT, UNDER ANY CIRCUMSTANCES, PROVIDE MY INSURER WITH MY CONFIDENTIAL MEDICAL HISTORY WITHOUT MY EXPLICIT CONSENT. IN THE EVENT SUCH A REQUEST IS RECEIVED, THE INFORMATION WILL BE FORWARDED TO ME DIRECTLY FOR REVIEW AND AUTHORIZATION.
I UNDERSTAND THAT, IN THE CASE OF UNUSUAL REQUESTS FOR DISCLOSURE, I WILL BE CONTACTED FOR SPECIFIC PERMISSION, AND I MAY BE ADVISED IF SUCH DISCLOSURE IS INAPPROPRIATE.
I AM AWARE THAT I MAY WITHDRAW MY CONSENT TO THE USE OR DISCLOSURE OF MY PERSONAL INFORMATION AT ANY TIME. I FURTHER UNDERSTAND THAT THE POTENTIAL CONSEQUENCES OF SUCH WITHDRAWAL, AS WELL AS THE PROCESS FOR DOING SO, WILL BE EXPLAINED TO ME UPON REQUEST.