New Patient Form

First Name *

Last Name *

Prefer to be called

Gender *

Date of Birth *

Adult or Child? *

Marital Status *

Address *

Email Address *

Mobile Phone # *

Home Phone #

Work Phone #

Preferred Contact Methods *

Email

Text Mobile Phone #

Call Mobile Phone #

Call Home Phone #

Call Work Phone #

Are you available on short notice for future appointments? *

Occupation *

Employer/School *

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Family Physician Name

Family Physician Phone #

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In Case of Emergency, Notify: *

Relation *

Phone # *

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Person Responsible For This Account: * Person Responsible For This Account:

Name (if different from self) *

Mobile Phone # *

Work Phone # *

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How did you hear about us? If person, specify name. *

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Yes

No, I am the responsible party

Do you have secondary insurance?

Yes

No

Primary Insurance Information

Subscriber Name *

Subscriber ID *

Date of Birth *

Relation * Relation

Insurance Company *

Policy Plan # *

Are you familiar with your plan details?

Yes

No

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Secondary Insurance Information

Subscriber Name *

Subscriber ID *

Date of Birth *

Relation * Relation

Insurance Company *

Policy Plan # *

Are you familiar with your plan details?

Yes

No

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Yes

No

If so, please specify: *

Are you presently under the care of a physician? *

Yes

No

If so, please explain: *

Have you had a medical examination in the last year? *

Yes

No

Do you use any prescription or non-prescription drugs regularly? *

Yes

No

Please specify: *

Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex? *

Yes

No

Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea? *

Yes

No

Please specify: *

Have you ever experienced any unusual reaction to any of the following? *

If so, please explain: *

Have you been warned against taking any drug or medication? *

Yes

No

Do you bruise easily or bleed abnormally? *

Yes

No

Do you require pre-medication for dental treatment? *

Yes

No

Have you ever had any organ implants or medical implants? *

Yes

No

Have you ever fainted? *

Yes

No

Do your ankles swell? *

Yes

No

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? *

Yes

No

Do you have frequent headaches? *

Yes

No

Do you have AIDS or you have ever tested positive for HIV? *

Yes

No

Do you have any of the following? Please check any that apply. *

Have you had any injury, surgery or x-ray therapy to your face or jaws? *

Yes

No

Do you have any disease, condition, or problem you think the doctor should know about? *

Yes

No

Are you pregnant or suspect you might be? *

Yes

No

If so, what month are you in? *

Are you taking birth control pills? *

Yes

No

Are you nursing? *

Yes

No

Exam

Cleaning

Emergency

OtherOther

Do you presently having dental pain? *

Yes

No

Is there a dental problem you would like to take care of as soon as possible? *

Yes

No

How frequently do you see your dentist? *

How frequently do you see your dentist?

How often do you brush your teeth? *

How often do you floss your teeth? *

Do your gums bleed easily? *

Yes

No

Are your teeth sensitive to: *

Do you feel you have bad breath at times? *

Yes

No

Have you ever had jaw joint surgery? *

Yes

No

Do you have pain in your jaw joints or suffer from migraine headaches? *

Yes

No

Does any part of your mouth hurt when clenched? *

Yes

No

Does your jaw crack or pop when opened widely? *

Yes

No

Have you had (check any that apply): *

Do you grind or clench your teeth during the day or night? *

Yes

No

Do you smoke? *

Yes

No

If so, specify number per day: *

Do you or does any family member have a problem with snoring? *

Yes

No

Have you ever experienced growths or sore spots in your mouth? *

Yes

No

If so, where? *

Have you had any previous problems with dental treatment? *

Yes

No

Specify: *

Are you satisfied with the appearance of your teeth? *

Yes

No

Specify: *

Any other dental concerns?

Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise a $50 charge is applied.

Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

*

I have reviewed and agree to the above information

Signature *

Relationship to the Patient: * Relationship to the Patient:

Name if not the patient *

Financial Policy

At Westheights Dental Centre we strive for excellent service and care at the current fee guide established by the Ontario Dental Association (ODA FEE GUIDE) therefore, payment is required at each dental visit. We accept – Cash, Visa, Mastercard, and Interac. If you have dental insurance benefits, we will submit your claims electronically. Your insurance carrier will reimburse you at the percentage your coverage allows. Should you require extensive cosmetic or restorative dentistry you may qualify for special financial arrangements based on your dental treatment. Payments from your dental insurance may take from 2-6 weeks. We will do our best to help you understand your dental coverage plan, questions about fees and coverage should be answered by your carrier.

Cancellation Policy

All of our dental visits require preparation prior to your arrival, therefore; we require 2 business days should an appointment change be necessary so that we can replace the vacant spot to someone who needs treatment. As a courtesy, you will receive a confirmation call two days before your next dental appointment. All missed appointments or insufficient notice of cancellations may be subject to a fee, which must be paid before the appointment can be rescheduled. Please note that the insurances do not pay for missed or cancelled appointments.

Permission To Use Photographs And X-Rays

I consent to the taking of photographs and x-rays before, during and after dental treatment as they are a necessary part of the diagnostic procedure and record keeping. I further give permission for the use of these photographs, x-rays and records to be shown to other patients and doctors for treatment and education purpose.

Privacy Policy

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

In this office, Dr. Ghada Al-Shurafa is the contact person for personal health information related matters. All staff members who come in contact with your personal health 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:

only necessary information is collected about you;
we only share your information with your consent;
storage, retention and destruction of your personal health information complies 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 member of our office staff.

How Our Office Collects, Uses and Discloses Patients’ Personal Health Information

Our office understands the importance of protecting your personal health information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

This office will collect, use and disclose personal health information about you for the following purposes:

to deliver safe and efficient patient care
to identify and to ensure continuous high quality service
to assess your health needs
to provide health care
to advise you of treatment options
to enable us to contact you
to establish and maintain communication with you
to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
to communicate with other treating health care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
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
for teaching and demonstrating purposes on an anonymous basis
to complete and submit dental claims for third party adjudication and payment
to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company
to assess liability and quantify damages, if any
to prepare materials for the Health Professions Appeal and Review Board (HPARB)
to invoice for goods and services
to process credit card payments
to collect unpaid accounts
to assist this office to comply with all regulatory requirements
to comply generally with the law

Patient Consent

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

Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.

You may withdraw your consent for use or disclosure of your personal health information at any time.

Checkboxes *

I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information. I agree that Westheights Dental Centre can collect, use and disclose personal health information as set out above in the information about the office’s privacy policies.

Signature *

Relationship to the Patient: * Relationship to the Patient:

Name if not the patient *

Patient Information

Primary Insurance Information

Secondary Insurance Information

Emergency! If you are in need of urgent dental care we will try our best to see you immediately.

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