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 Call: 204-488-7025

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
No

Name:

Address:

Text message
Cell
Home
Work
E-mail

Financial Information

Cash
Cheque
Credit card
Insurance
Other
Self
Spouse
Parent/guardian
Other

Address:

Primary Insurance

% coverage

Secondary Insurance

% coverage

Medical History (This Information Will Remain Confidential)

Medical History

YES
NO
YES
NO

List medications or drugs you are taking at this time.

YES
NO
Antibiotic — penicillin
Sulfonamide
Other
Aspirin
Barbiturates (sleeping pills)
Codeine
Local anesthetic
None
YES
NO
YES
NO
YES
NO

Do you bruise easily or have prolonged bleeding?

YES
NO
YES
NO

Have you ever fainted, or had shortness of breath or chest pain?

YES
NO

For women,

YES
NO
YES
NO
YES
NO

Medical history

Clear
Not Clear (please choose from list)
A.I.D.S.
Cancer
Heart disease/attack
Jaundice
Rheumatic/Scarlet fever
Anemia
Circulation problem
Heart murmur
Kidney disease
Sickle cell disease
Angina
Liver disease
Congenital heart lesions
Sinus trouble
Heart pacemaker/surgery
Anorexia
Leukemia
Heart rhythm disorder
Steroids
Hepatitis A/B/C
Diabetes
Lung disease
Artificial heart valve
Stroke
High/low blood pressure
Arthritis
Herpes
Drug/alcohol depcndence
Thyroid disease
Mental/nervous disorder
Artificial joints
Emphysema
Tuberculosis
H.I.V. positive
Mitral valve prolapse
Asthma
Epilepsy
Glandular disorders
Blood disorders
Organ transplant/implant
Hodgkin disease
S.T.I's
Bronchitis
Ulcers
Hyper (hypo) glycemia
Bulimia
Hypertension
Head/neck injuries
Radiation/chemotherapy

For children, Have you recently (within 2-3 weeks) had any of the following (approximate date)?

None

Dental History

Have you ever had local anesthetic (freezing)?

YES
NO

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.

Self
Parent/guardian

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.

Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information comply with existing legislation and privacy protocols;
Our privacy protocols comply with privacy legislation, standards of your regulatory body, and the law.

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

Please be assured that every employee in our office is committed to confidentiality and ensuring you receive the best quality care.

How Our Office Collects, Uses and Discloses Patients' Personal Information

Our office understands the importance of protecting your personal information. Outlined below is how our office will collect, use and discloses your information.

To deliver safe and efficient patient care
To identify and ensure continuous high-quality service
To advise you of your treatment options
To establish and maintain communication with you
To communicate with other treating and health-care providers, including specialists and referring doctors
To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
To allow us to efficiently follow-up for treatment, care and billing
To complete and submit claims to third party adjudication and payment
To comply with legal and regulatory requirements, including the delivery of patient's charts and records (x-rays) to governing bodies in a timely fashion, when required according to PIPEDA-Personal Information Protection and Electronic Documents Act
To permit potential purchasers, practice brokers, or advisors to evaluate the practice or conduct an audit
To invoice for goods and services, process credit card payments, and for unpaid collection purposes
To comply generally with the law

By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

Your information may be accessed by regulatory authorities under the terms of PIPEDA and for the defence of a legal issue.

Our office will not under any conditions supply your insurer with your confidential medical history. In the event this type of request is made, we will forward the information directly to you for your review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.

You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.

GENERAL INFORMATION

Grant Dental Centre

1537 Grant Ave

Winnipeg, MB

R3N 0M3

P: 204-488-7025

E: grantdentalcentre@shaw.ca

HOURS

Monday – Friday: 8:30 AM ─ 5:00 PM
Weekday Evening: Limited Hours
Saturday: Limited Hours

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