New Patient Registration

New Patient Registration

Welcome to the Studio.
Name *

First NameLast Name
Address*

Street Address

CityProvince

Postal CodeCountry
D.O.B*
Cell Phone Number*
Email*
example@example.com
Emergency Contact Info
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to Patient
Medical Information
Current Dentist /Dental Hygienist (name and telephone number if known)
Current Physician (name and telephone number if known)
Medical History
Are you in good health?*

YesNo
If no, please explain.
Have you been hospitalized in the past 5 years?*

YesNo
If yes, list reason and date.
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.*
Do you use tobacco/nicotine products?*

YesNo
If so, which type and how often?
Do you have any allergies? if so, to what?*
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?

YesNo
Have you ever been told to take a premedication prior to dental treatment/ dental cleanings? If so, is it still required? Please explain.
Have you experienced any of the following CHD conditions? (Antibiotic prophylaxis is recommended).*

NoneArtificial (prosthetic) valvePrevious infective endocarditisDamaged valves in transplanted heartCHD; unrepaired cyanotic CHDCHD; repaired completely in last 6 monthsCHD; repaired with residual defects
Please indicate if you have or have had any of the following diseases or problems.

Cardiovascular diseaseHigh/low Blood pressureArthritisSystemic lupus erythematousEating disorderGI reflux/ persistent heart burnAutoimmune diseaseAsthmaHeart murmurOther congenital heart defectAnemiaAIDS/HIVRheumatoid arthritisCancer/chemotherapy/radiationDiabetes 1 or 2Gastrointestinal diseaseThyroid problemStrokeSleep disorder. (CPAP machine)Recurrent infectionsOsteoporosisFainting spells or seizuresKidney problems/dialysisHepatitis, jaundice or ulcersMental health disorderSevere headaches/ migrainesHerpes, cold sores, fever blisters
Women, Are you?

Taking birth control or hormone replacementNursingPregnantTrying to get pregnant
Do you have any diseases or problems not listed above that you think I should know about?*

YesNo
If yes, what?
Grind your teeth?*

PresentPastNeverUnsure
Mouth breather?*

PresentPastNeverUnsure
Are you currently experiencing pain in your mouth?*

YesNo
Are your teeth sensitive to biting /chewing/temperature changes/sweets*

PresentPastNever
Have you ever worn a night guard?*

PresentPastNever
Have you had a serious injury to your mouth or head?*

PresentPastNever
What is your "usual" schedule for dental cleanings? *
(Ex. Every 3, 4, 6, 12 months)
Date of last dental check up and cleaning?*
Payment Options

We accept Visa, MasterCard, Debit, Cash and American Express and E-Transfer.
Which payment option would you prefer?*

Option 1: Paid in full at time of service, we can submit on your behalf to your insurance or you can submit to your insurance on your own. Insurance will then reimburse you directly.Option 2: No Insurance, Paid in full at time of service.Option 3: Assignment of Benefits: Your insurance carrier must allow ‘Assignment of Benefits and accept EDI's. We will submit your dental claim to your insurance carrier on your behalf, and you will be responsible for the remaining portion not covered through your insurance. A valid credit card MUST remain on file. This includes dual insurance holders. It is your responsibility to notify Red Deer Dental Hygiene Studio Inc of any changes which affect your credit card account. Your account must remain in ‘good standing’ and any outstanding/uncollectible balance for more than 45 days will no longer be considered eligible for Direct Billing services offered.
I consent and authorize Red Deer Dental Hygiene Studio Inc to keep my signature on file and to issue a credit or debit memo to my credit card account for any over and under payment once my insurance portion has been received. I will be notified by telephone/text or email if my account is charged or credited within an excess of $250.

I give my permission for any claim not paid by my insurance company for myself and any family member listed on my joint account to be automatically charged to my credit card if payment has not been recieved within 45 days of date of service. A receipt for this transaction will be emailed with a paid statement.

If you do not wish to leave a credit card number on file, Option 3 is not an option. credit card number will be collected at time of appointment
Signature agreeing you above payment option*

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Insurance Information

RDDHS conveniently offers direct billing to most major insurance companies. COB's may or may not be accepted **
Name of primary policy holder

First NameLast Name
D.O.B. of primary policy holder
Primary Insurance name
Alberta blue cross, Manulife, green shield, equitable life etc
Insurance ID or Certificate #
Policy #
Patients relationship to policyholder:
Name of SECONDARY policyholder
D.O.B. of secondary policyholder
Secondary Insurance name
Policy or group #
Insurance ID or Certificate #
Patients relationship to policyholder:
Patient Consent Form:

For Collection, Use and Disclosure of Personal Information Privacy of your personal information is an important part of our office providing you with quality dental 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. Darci McNally, RDH acts as the Privacy Information Officer at Red Deer Dental Hygiene Studio Inc. 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. 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 existing legislation and privacy protection protocols; ● Our privacy protocols comply with privacy legislation, standards of our regulatory body, CRDHA, and the law. Do not hesitate to discuss our policies with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
I consent to the collection of my personal information and give Red Deer Dental Hygiene Studio Inc. *

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