New Patient Form

In an effort to serve you better, we ask that you complete the following form. We will be glad to assist you with any questions you have.

PATIENT INFORMATION

Your Name:*

Date of Birth:*

Your Address:*

Age

Sex

Marital Status

Employer

Name of Spouse

CONTACT INFORMATION
Emergency Contact:
Phone Number:
Family Doctor:
Phone Number:
REFERRAL SOURCE
How did you hear about us?
FINANCIAL INFORMATION
Do you have Dental Insurance?* Yes   |   No

If yes, please fill in the following insurance information. Otherwise, skip this section.

Insurance Company

Insurance Year End:

% Coverage For:

Name of Insured (if different from above):

Date of Birth:*

Insured Address:*

DENTAL HISTORY

Is there a dental problem you would like treated immediately?  Yes  No

How frequently do you see your dentist?  3-6 months  Annually  Other:

Date of your last dental visit?  

Date of your last dental X-Ray?  

Have you had any of the following?    Periodontal treatment    Orthodontic treatment    A bite plate or any other appliance    Your bite adjusted or teeth ground    Oral surgery

If you answered "yes" to oral surgery, who performed the surgery?
When was it done?
Are you being followed up by a dental specialist?

Are there any growths or sore spots in your mouth?  Yes  No

Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?  Yes  No

Have you noticed any loose teeth, or, have any of your teeth shifted?  Yes  No

Does food get caught between your teeth?  Yes  No

Are your teeth sensitive to: Cold Sweets Heat Other

Have you been advised to take antibiotics before a dental appointment?  Yes  No

How often do you brush per day?   Floss?   Use anti-bacterial rinse?

Do you have bad breath or bad taste in your mouth?  Yes  No

Have you ever experienced any of the following jaw problems?
Popping/clicking in jaw joints
Pain in jaw joints, around ear, or side of the face
Difficulty in opening or closing
Pain when teeth are clenched
Pain or difficulty when chewing

Do you have any of the following habits?
Clenching or grinding your teeth while asleep or awake
Biting your cheeks or lips
Mouth breathing while awake or asleep
Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)

Have you ever had any problems with previous dental treatments?
 Yes   No      If yes, please specify?

Are you dissatisfied with your teeth?  Yes  No

MEDICAL HISTORY

Are you being treated for any medical condition at present or within the past two years?    Yes  No

If yes, explain:    Physician:    Phone:

Have you been hospitalized in the past two years?    Yes  No

When was your last visit to a physician?    Last complete physical exam?

Have you recently, or are you presently taking any prescription or non-prescription drugs (including herbal)?   Yes  No If yes, which one(s)?

Have you ever reacted adversely to any medications or injections? (e.g. Penicillin, or other antibiotics, aspirin, codeine, local anesthetic (freezing), nitrous oxide, or any other medicine)   Yes  No
   If yes, which one?

Have you ever been advised against taking any specific type of medication?    Yes  No

Do you any of the following: asthma, hay fever, food allergies, metal or latex allergies?    Yes  No    If yes, which one?

Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?     Yes  No    If yes, which one?

Is there a family history of diabetes, cancer, or heart disease?    Yes  No    If yes, which one?

Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?    Yes  No

Do your ankles, feet, or hands swell?    Yes  No

Has your weight, appetite, or energy level changed dramatically recently?    Yes  No

Do you follow a special diet, or are you on a diet pill therapy?    Yes  No    If yes, describe:

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?    Yes  No

Have you tested HIV positive?    Yes  No

Have you ever had any injury or surgery to your face or jaws?    Yes  No

Do you have FREQUENT SEVERE headaches, earraches, or eat/throat infections?    Yes  No

Do you wear eyeglasses or contact lenses?    Yes  No

Do you have any hearing difficulties?    Yes  No

Do you smoke or use any forms of tobacco?    Yes  No    If yes, are you wearing the transdermal nicotine patch?  Yes  No

Are you alcohol and/or drug dependent?    Yes  No

Check off the conditions that you presently have or have ever had:

   AIDS
   Anemia
   Angina Pectoris
   Arthiritis/Rheumatism
   Artificial Heart Valve
   Artificial Joints (Hip/Knee)
   Asthma
   Blood Disorders
   Bronchitis
   Cancer
   Circulation Problems
   Congenital Heart Lesions
   Cortisone/Steroid
   Chron's Disease
   Diabetes
   Emphysema
   Epilepsy or Seizures
   Fainting or Dizzy Spells

   Glandular Disorders
   Glaucoma
   Head/Neck Injuries
   Heart Disease or Attack
   Heart Murmur
   Heart Pacemaker
   Heart Rhythm Disorder
   Heart Surgery
   Hepatitis A/B/C
   Herpes
   High/Low Blood Pressure
   Hodgkins Disease
   Hyper/Hypo Glycemia
   Hypertension
   Inflammatory Bowel Disease
   Jaundice
   Kidney Disease
   Liver Disease

   Lung Disease
   Lupus
   Malignant Hyperthermia
   Mental/Nervous Disorder
   Mitral Valve Proplapse
   Organ Transplant / Medical Implant
   Psychiatric Treatment
   Radiation Treatment / Chemotherapy
   Scarlet Fever - Rheumatic Fever
   Sickle Cell Disease
   Sinus Trouble
   Stomach/Intestinal Problems or Ulcers
   Stroke
   Thyroid Disease
   Tuberculosis
   Veneral Disease
   Other

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Do you currently have, or have you had in the past any disease or condition not listed?    Yes  No    If yes, which one?

Is there anything else we should know about your health?

Do you wish to speak PRIVATELY to the doctor about any problem or medical condition?    Yes  No

WOMEN ONLY:

Are you pregnant or maybe?    Yes  No   If yes, expected delivery date:

Are you breast feeding?    Yes  No

Are you taking birth control pills?    Yes  No

NOTE: IT IS IMPORTANT THAT ANY CHANGE IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE.
GENERAL RELEASE
I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

PRIVACY CONSENT

For Collection Use and Disclosure Information

Privacy of a patient is an important part of our office. We understand the importance of protecting personal information. We are committed to collecting, using, and disclosing your personal information. In this office, all staff members who come in contact with your personal information are aware of the sensitive nature of the information you 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 information complies with every legislation and privacy protection protocols
  • Our privacy protocols comply with privacy legislation standards of our body of the royal college of Dental Surgeons of Ontario, and the law

Do not hesitate to discuss our polices with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensure that you receive the best quality dental care.

How Our Office Collects, Uses and Discloses Patients Personal Information

Our office understands the importance of protecting your personal 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 information about you for the following purposes:

  • To deliver safe and efficient patient care
  • To identify and to ensure continuous high quality service
  • To asses 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 the relationship to the oral and maxillofacial complex and dental care enerally
  • To communicate with other treating health care providers, including specialist and general dentists who are the referring dentists and/or peripheral dentists
  • To allow us to maintain communication and contract with you to distribute healthcare information and to book and confirm appointments
  • To allow us to efficiently follow-up with treatment care and billing
  • For teaching and demonstrating purposes on an anonymous basis
  • To complete and submit dental claims for third party adjunction 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 protection act.
  • To comply with agreements/undertakings entered 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 of advisors to evaluate the dental practice
  • To allow the potential purchasers, practice brokers or advisors to conduct in preparation for a practice sale
  • To deliver your charts and records to the dentist's insurance carrier to enable the insurance company to asses liability and quantity changes, if any
  • To prepare materials for the Health Professionals 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 the regulatory requirements
  • 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 disclosures or 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. You information might be accessed by the regulatory authorized under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling it's manors under the RHPA, and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medial history. In this event, at this time, where a request is made, we will forward the information directly to you for review and for your specific consent. When usual 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 review your consent for the use of disclosure of your personal information and we will explain the ramifications of that decision, and the process.


I have reviewed the above information that explains how your office will use my personal information and the steps your office is taking to protect my information. Now that your office has a privacy code, and I can ask to see the code at any time, I agree that Brody Family Dental can collect, use and disclose my personal information as said above about the offices privacy policy.

DENTAL INSURANCE POLICY

In order to make your dental visit more convenient, our office offers to bill your insurance directly. However:

  • Keep in mind that the doctor does not have a contract with the insurance companies, YOU DO!
  • Any deductible and /or co-payment are due upon treatment.
  • Although we try our best to keep within your insurance coverage, this may not always be possible. Insurance companies do not give us every little detail on dental policies, therefore we cannot guarantee that all treatment rendered will be fully covered.
  • Please note that some insurance companies have a non-assignment policy, which means that they DO NOT send cheques directly to the dentist. Patients with such policies are required to pay at the time of their appointment.
  • Our office does not give a discount for any amount that is not covered by your insurance. For example, if you are covered at 80%, we cannot write off the 20%. This is your balance and you are required to pay this at the time of your appointment. It is considered insurance fraud if we write off the difference.
  • If you want us to receive payment from a third party (Your Insurance Company) we will accept the assignment of fees, but we need authorization from you to allow us to receive payment from your insurance company. We also require authorization from you to allow us to supply the insurance company with any information they may require pertaining to any claims we submit on your behalf. This may include forms such as progress notes, charting, radiographs, etc.
  • Please inform us immediately of any changes to your insurance policy, your home address and phone numbers.


I have read and understood the above information and had the opportunity to ask questions and receive answers. I understand that responsibility for payment of the dental services for my dependents and myself is mine, and I assume responsibility for fees associated with these services. I authorize Brody Family Dental to receive payment from my insurance company directly.