New Patient Form

Name:

First NameLast Name

Date of Birth:

Date

Sex:

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (HOME)

Area CodePhone Number

Mobile Number

Area CodePhone Number

Email

example@example.com

Family Doctor and Phone Number:

How did you learn about our dental office?

Do you have dental insurance coverage? If so, please provide the details:

Please answer the following questions:

1. Are you under any medical treatment? Please list:

YesNo

2. Are you taking any medication? Please list:

YesNo

3. Are you allergic to penicillin or drugs ? Please list:

YesNo

4. Do you have any allergies? Please list:

YesNo

5. Have you ever been hospitalized? When?

YesNo

Date

6. Have you ever had surgery? Please list:

YesNo

7. Have you had any conditions of illness not listed below?

YesNo

8. (WOMEN) Are you pregnant?

YesNo

9. Do you wear contact lenses?

YesNo

10. Do you smoke? How much?

YesNo

11. Have you had abnormal bleeding associated with previous extractions?

YesNo

12. Have you had abnormal reactions to local anesthesia?

YesNo

13. Are you happy with your smile?

YesNo

How can we help?

Please let us know if you have any dental concerns:

Please check any of the following conditions that apply:

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION TO DENTIST

IN THE MATTER OF THE PERSONAL INFORMATION PROTECTION AND ELECTRONIC DOCUMENTS ACT

I authorize release to Capitol Hill Dental Clinic information contained in pre- authorizations and claims submitted electronically and otherwise, and information pertaining to my dental coverage and benefits, icluding but not limited to history of claims and payment of benefits.

I also authorize the use of all my patient records by the care providers at Capitol Hill Dental Clinic for the purpose of consultation and discussion with peers and colleagues in private and professional settings.

The authorizationshall continue in effect until the udersigned revokes the same.

Image/photo of yourself:

Browse Files

Signature of patient/guardian:

Date:

Date

Cancellation Policy

There are many instances when our patients require urgent or emergency treatment and therefore, require an appointment as soon as possible. When patients give the clinic advanced notice of their need to cancel a scheduled appointment, this time can be allocated to the patients in need of urgent treatment. In this way, the clinic can best serve the needs of ALL patients.

Bearing these special needs in mind, the clinic requires a minimum of 2 working days of notice if an appointment must be cancelled. A patient research project carried out by the Canadian branch of the Academy of General Dentistry, the second largest dental organization in the world, shows that most patients who cancel appointments do so in the belief that a scheduled appointment is a matter of convenience, whereas patients who keep their appointments do so because they see a scheduled appointment as a commitment to be honoured. Surveyed patients who cancel scheduled appointments were surprised to discover that a cancelled appointment on notice (less that 2 working days) can adversely affect many other patients, specifically those who are suffering and in pain. Keeping in mind that the goal of Capitol Hill Dental Clinic is to serve the needs of all patients, especially the needs of those in acute pain, the practice policy is that patients wishing to change their commitment to scheduled appointments for the sake of their convenience, must give the practice a minimum of 2 working days notice. If less that 2 working days notice is given to cancel an appointment, a $75.00 fee* will be assessed. In the event that no notice is given and the patient does not show up for their scheduled appointment, a $75.00 fee will be assessed.

In the event that a patient does not show up on a second occasion, the practice policy is to ask the patient to find a different practice, at which point our administrative staff will be happy to transfer that patient’s records to a new office with a letter explaining why the transfer is being made. Please note that insurance companies do not cover fees for broken appointments, therefore payment is the patients’ responsibility.

Exceptions will be made for illness or personal tragedy

Payment Policy

Unless prior arrangements have been made, payment is due upon completion of treatment. Please note that not all services may be covered by insurance carriers and every insurance plan has its own unique “quirks” and exceptions. It is the patients’ responsibility to cover procedures that are not covered by their insurance plan.

We at Capitol Hill Dental Clinic look forward to taking care of your oral health needs and welcome you and your family to our team of dental professionals!

I have read the above policies of Capitol Hill Dental Clinic and understand my responsibilities as a patient.

Signature of patient/guardian:

Date

NEW PATIENT FORM