• Patient Information

  • Current Date
     - -
  • Gender*
  • Do you have an email?*

  • Responsible Party*
  • Does the patient has any siblings (under 18 years) accompanying for the same appointment?*
  • Do you have any kids (under 18 years old) accompanying you for the same appointment?*
  • Are you a new patient?*

  • Responsible Party's Information

  • Relation to the patient*

  • Existing Patient

  • If there is change in any of the following, please check the box*

  • Phone Number

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Medical Update

  • Is there any change in the Family Physician?
  • Is there any update in your medication?
  • Is there any update in your allergies?
  • Is there any update in your medical conditions?
  • Is there anything else that we should know?
  • Are you pregnant?

  • Insurance Update

  • Please Specify

  • Primary Insurance

  • Do you wish to upload the picture of Insurance Card or fill the details?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Secondary Insurance

  • Do you wish to upload the picture of Insurance Card or fill the details?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Guillaume Racicot or Rayside Dental. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -

  • New Patient

  • Telephone

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Insurance Policy Information

    Please provide us with your Insurance Benefits Card
  • Do you have insurance?*
  • Please specify*

  • Primary Insurance

  • Do you wish to upload the picture of Insurance Card or fill the details?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Secondary Insurance

  • Do you wish to upload the picture of Insurance Card or fill the details?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Guillaume Racicot. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -

  • Medical Health History

  • Do you have a medical specialist?

  • If you have a printed medication list, please provide it to the front staff. Thank you.

  • Allergies

  • Do you have any Allergies or Adverse Reactions? (Medications, Latex, Food, Other)*
  • Are you sensitive or have adverse reactions to any metals?*
  • Are you allergic or have adverse reactions to Aspirin?*
  • Are you allergic or have an adverse reaction to Barbiturates (sleeping pills)?*
  • Are you allergic or have an adverse reaction to codeine?*
  • Are you sensitive or have adverse reactions to Penicillin?*
  • Are you sensitive or have an adverse reaction to Sulfa Drugs?*
  • Are you allergic or have adverse reactions to Local Anesthetic (freezing)?*
  • Are you allergic or have adverse reactions to Nitrous Oxide?*
  • Are you allergic or have adverse reactions to any other drugs?*

  • Medical Conditions

  • Rows
  • Have you ever been treated for or told you have Arthritis?*
  • Have you ever been treated for or told you have Asthma?*
  • Have you ever been treated for or told you have a blood disorder such as Anemia or Leukemia?*
  • Have you ever been treated for or told you have Cardiovascular Disease? (Heart attack / open heart surgery / Stroke / etc)*
  • Have you ever been treated for or told you have Diabetes?*
  • Have you ever been treated for or told you have Emphysema?*
  • Have you ever been treated for or told you have Epilepsy?*
  • Have you ever been treated for or told you have heavy bleeding?*
  • Have you ever been treated for or told you have Hypertension?*
  • Have you ever had Joint Replacement*
  • Have you ever been treated for or told you have Liver Disease?*
  • Have you ever been treated for or told you have a Mental Disability by a Doctor? (Anxiety / Depression / etc)*
  • Have you ever been treated for or told you have Renal Disease?*
  • Have you ever been treated for or told you have Rheumatic Fever?*
  • Have you ever been treated for or told you have Thyroid Disorder?*
  • Have you ever been treated for or told you have Tuberculosis?*
  • Have you been diagnosed with any disease, condition or problem not listed above?*
  • Do you consume alcohol?*
  • Do you consume recreational drugs?*
  • Is there anything else that we should know?*
  • Is there anything else about your health we should be aware of ?*
  • Are you pregnant?*
  • Do you wish to speak to the doctor privately about any problem or medical condition?*

  • Dental History

  • Do you have a previous general Dentist?*

  • Information Release

  • To 

    {generalDentist}

    {dentalPractice}

    {dentalPractice594}

     

    I authorize the above Dentist to release my dental records, including x-rays and the last record of the requested treatment to:


    Rayside Dental
    Dr. Guillaume Racicot

    4764-34, REGIONAL ROAD #15
    CHELMSFORD, ON
    POM 1LO
    Phone: 705-855-4449

    Fax: 705-855-0072

     

    Please send digital x-rays to raysidedental@live.com

    I release you from all legal responsibility or liability that may arise from this authorization.

  • Date
     - -
  •
  • Which oral hygiene aids do you currently use:
  • Please check all that apply to your current Dental situation:
  • Rows
  • Did you have periodontal treatment?
  • Did you have orthodontic treatment?
  • Do you own / wear an occlusal appliance (night guard) ?
  • Do you have any missing teeth?
  • Are you interested in Implants to replace the missing teeth?
  • Did you have any prior vehicle accident or trauma to head, neck, jaw(s) and/or teeth?
  • Do you have or had any serious dental problems, diseases or conditions that are not listed above?

  • Family Member

    • Family Member 1 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Medical History

    • Information Release

    • To {previousGeneral}

      I authorize the above Dentist to furnish my child's {name1272} dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 2 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral360}

      I authorize the above Dentist to furnish my child's {name2276} dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 3 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral361}

      I authorize the above Dentist to furnish my child's {name3316} dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 4 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral362}

      I authorize the above Dentist to furnish my child's {name4317} dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 5 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral363}

      I authorize the above Dentist to furnish my child's {name5318} dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 6 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's {name6319}  dental records, including x-rays and the last record of the requested treatment to:

      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 7 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's {name7539}  dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?
    • Family Member 8 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's {name8564}  dental records, including x-rays and the last record of the requested treatment to:


      Rayside Dental
      Dr. Guillaume Racicot

      4764-34, REGIONAL ROAD #15
      CHELMSFORD, ON
      POM 1LO
      Phone: 705-855-4449

      Fax: 705-855-0072

       

      Please send digital x-rays to raysidedental@live.com

      I release you from all legal responsibility or liability that may arise from this authorization.

    •
    • Which oral hygiene aids does your child currently use:
    • Please check all that apply to your child's current Dental situation:
    • Rows
    • Rows
    • Rows
    • Does your child have or had any serious dental problems, diseases or conditions that are not listed above?

  • Appointment & Office Policies

  • It is important to remember that your insurance policy is a contract between you, your employer and the insurance carrier. The patient is ultimately responsible for their account, and any discrepancy regarding reimbursement will be between the patient and the insurance carrier. It is also your responsibility to make sure of the validity of your dental benefit the day of the appointment.


    When needed, we will prepare a treatment plan which will be sent to your insurance company. The insurer (you) will get an answer from the insurance by mail or email which you will be required to consult on your dental benefit’s website, as well as notify your dental office. 


    At the end of your appointments, please stop at the front desk and a receptionist will submit your claim electronically when permitted or print a claim form to sign. We will revise with you the treatment received. At this time, any balances will be presented to you and payment will need to be settled.


    You are also responsible to inform our office of any changes regarding your dental benefit, address, telephone number and any changes in your health.


    Our office will confirm your hygiene appointment one week prior. Our dental clinic requires a minimum 2 business day’s notice if any appointment needs to be rescheduled/cancelled. This way, you will avoid $25 fee for last minute cancellation and time could be allocated to another patient.


    At Rayside Dental, our goal is for you to have a pleasant experience in our office. We strive to help you attain a high level of dental and overall well-being.

  • Date
     - -
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