Dadswell Denture: New Patient Form

Name*

Title

Date of Birth*

MonthDayYear

Sex

MaleFemale

Address

Street Address Line 2

Phone (Home)

Phone (Business)

Phone (Cell)

E-mail Address*

Occupation

Employer

Account Responsibility

Referred by

Emergency Contact Name

Emergency Contact Number

Insurance Company

Plan/Group/Policy #

Policy Holder's Name

Date of Birth

Relationship to Patient

Plan/Group #

ID #

Insurance Company

Plan/Group/Policy #

Policy Holder's Name

Date of Birth

Relationship to Patient

Plan/Group #

ID #

Dentist

Phone

Frequency of visits

BiannualEmergency OnlyAnnual

Do you grind your teeth?

YesNo

Do your jaw joints pop or grind?

YesNo

Are your gums tender or sore?

YesNo

Have you had any injuries or surgeries to your mouth?

YesNo

Details

Last Visit/X-ray

Do you have implants?

YesNo

Family Physician

Phone

Are you currently under medical treatment?

YesNo

Reason?

Last Visit

Have you ever been treated for any of the following

Diabetes RX

Epilepsy RX

Heart Condition RX

Thyroid RX

High Blood Pressure RX

Cancer RX

Repeat Headaches RX

Stroke RX

Allergies RX

Respiratory Disease/Asthma RX

HIV/AIDS RX

Hepatitis RX

Emotional or Nervous Disorders RX

Tuberculosis RX

Difficulty Swallowing RX

Osteoporosis RX

Joint Replacement RX

Difficulty Sleeping RX

Are you currently taking any medication for this condition or any other reason?

YesNo

Other RX

Do you smoke?

YesNo

Do you snore?

YesNoDon't know

Do you gasp or stop breathing in your sleep?

YesNoDon't know

Have you ever had any major operations or illness?

Medical History Updates. Specify

In our office, we are dedicated to ensuring the protection of our patients’ personal information and insuring that this information is used only in a professional manner. The following indicates some of the information that is collected, why we collect it, and when we may disclose your personal information. We collect, use and disclose your personal information where permitted or required by law.

Contact Information

We collect contact information from our patients such as full name, home address, home telephone number(s), home email address, work address, work telephone number(s), work email address, and cellular phone number. This information is considered as Contact Information and it is collected for a variety of purposes including the following:

To open and update a patient file;
To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts;
To process claims for payment or reimbursement from a third-party health benefit provider or insurance company*;
To send correspondence to our patients regarding need for further examination or treatments; and
To send correspondence to our patients regarding our clinic and practice.* Contact information is/may be disclosed to a third party health benefit provider or insurance company when submitting a claim on the patients’ behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

Medical/Dental History

We collect from our patients, information about their health history, family health history, physical and mental condition, their dental health history, and family dental health history. This Medical/Dental information is collected for a variety of purposes and may be used in part to assist us in diagnosing dental conditions and providing appropriate treatment for you, and may be disclosed for the following purposes:

To a third-party health benefit provider or insurance company, in the submission of a claim on behalf of the patient, for reimbursement or payment of all or part of the cost of the treatment ;
To a third-party health benefit provider or insurance company on behalf of the patient, in the submission of a preauthorization of treatment;
To other health/dental providers where, upon your consent, we are seeking a second opinion;
To other health/dental providers where, upon your consent, we have referred you to for additionalalternative treatment;

Financial Information

We collect information related to financial matters for facilitation of payment of your treatment(s).

Future Use

If consideration to sell this practice or a portion of this practice ever occurs, any qualified potential purchasers may be granted access as part of due diligence process to patient information, in order to verify information related to the sale. If this ever occurs, we will take necessary steps to ensure that the prospective purchaser protects any personal information, as we have done.

Regulatory

The College of Ontario Denturists regulates all Denturists in the Province of Ontario and as part of their regulatory function, may inspect our records and interview our staff in the process of their duties.

Consent

I hereby authorize and consent to the collection, use and disclosure of personal information concerning myself with regards to the above purposes, dated at the Town of Collingwood in the Province of Ontario, on {consentDate}.

Patient/Guardian Name:*

First NameLast Name

Consent Date

Date

Hour MinutesAM/PM Option

Please verify that you are human*

PATIENT INFORMATION

INSURANCE INFORMATION

Co-Insurance

DENTAL HISTORY

MEDICAL INFORMATION

PATIENT CONSENT

Contact Information

Medical/Dental History

Financial Information

Future Use

Regulatory

Consent