• WELCOME TO OUR OFFICE

    Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. Please answer the questions as accurately as you can. If you have any questions, please ask the treating dentist or receptionist, who is available to assist you with the completion of this form. All information is strictly confidential and will remain with this office.

  • REGISTRATION INFORMATION

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • The patient is an*
  • Title*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • MEDICAL PRIORITY

  • Format: (000) 000-0000.
  • Are you under the care of a medical specialist?*
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • FINANCIAL INFORMATION

  • Do you have insurance?*
  • Format: (000) 000-0000.

  • DENTAL HISTORY

    Please check Yes or No to each question. If unsure of question, please consult with dentist.
  • Is there of dental problem you would like treated immediately?*
  • Date of : last cleaning
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of : last visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of : last X-rays
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you been seeing a dentist regularly?*

  • Have you ever had any of the following?

  • Periodontal treatment (treatment of the gums)*
  • Orthodontic treatment (to straighten or realign the teeth)*
  • A bite plate or any other appliance?*
  • Your bite adjusted or teeth ground?*
  • Oral Surgery (surgery in or about the mouth / jaw joint, or implant surgery in one or both of your jaw joints)?*
  • Are there any growths or sore spots in your mouth?*
  • Do your gums bleed when brushing or eating, or, do you suffer from pain or swelling of your gums?*
  • Have you noticed any loose teeth, or have any of your teeth shifted?*
  • Does food catch between your teeth?*
  • Are any of your teeth sensitive to heat, cold, sweets or pressure?*
  • Have you been advised to take antibiotics before a dental appointment?*
  • Do you use dental floss, proxabrush, or stimudents?*

  • Have you ever experienced any of the following jaw problems

  • Popping / Clicking in your jaw points?*
  • Pain in your jaw joints, around your ear or side of your face?*
  • Difficulty in opening or closing?*
  • Pain when teeth are clenched?*
  • Pain or difficulty chewing?*

  • Do you have any of the following habits?

  • Clenching or grinding your teeth while awake or asleep?*
  • Biting your cheeks or lips?*
  • Mouth breathing while awake or asleep?*
  • Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?*
  • Do you have any emotional concerns about having dental treatment?*
  • Are you dissatisfied with the appearance of your teeth?*
  • Do you have trouble sleeping at night?*
  • Have you ever has any side effects form local/general anesthesia or sedation?*
  • Have you ever had an upsetting experience in the dental office, or any complications during or following dentaltreatment, or do you have any questions or concerns?*
  • Do you have trouble sleeping at night due to snoring or shortness of breath?*

  • HEALTH HISTORY

    Please check Yes or No to each question. If unsure of question, please consult with dentist.
  • Are you being treated for any medical condition at present or within the past two years?*
  • Has there been any change in your general health in the past year?*
  • Have you been hospitalized in the past two years?*
  • When was your last visit to a physician?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you recently or are you presently taking any PRESCRIPTION or NON-PRESCRIPTION drugs?*

  • Have you ever reacted adversely to any of the following: (please select)

  • *
  • Have you ever been advised against taking any specific type of medication?*

  • Do you have any of the following?

  • *
  • Do any of these allergic conditions result in headache, nausea, swelling, shortness of breath, or chest constriction?*
  • Has any family member had diabetes?*
  • Do you bleed excessively from a cut or injury, or bruise easily?*
  • Do your ankles, feet or handles swell?*
  • Has your weight, appetite, or energy level changed dramatically recently?*
  • Do you experience shortness of breath, or chest pain when taking a walk or climbing stairs?*
  • Do you follow a special diet?*
  • Have you tested HIV Positive?*
  • Do you have FREQUENT SEVERE headaches, ear aches, ear/throat infections?*
  • Have you ever had any injury or surgery to your face or jaws?*
  • Have you ever been or are you now a victim of family violence?*
  • Do you have any hearing difficulties?*
  • Do you smoke or use any other form of tobacco?*
  • Are you wearing a transdermal nicotine patch?*
  • Are you alcohol and/or drug dependent?*
  • Have you received treatment?*

  • Indicate which of the following you presently have or ever had

  • AIDS*
  • Anemia*
  • Angina pectoris*
  • Arthritis / Rheumatism*
  • Artificial Heart Valve*
  • Artificial Joints (Hip, Knee)*
  • Blood Disorders*
  • Bronchitis*
  • Cancer*
  • Circulation Problems*
  • Hyper / Hypo Glycemia*
  • Hypertension*
  • Jaundice*
  • Kidney Disease*
  • Liver Disease*
  • Lung Disease*
  • Malignant Hyperthermia*
  • Mental / Nervous Disorder*
  • Mitral Valve Prolapse*
  • Organ Transplant*
  • Congenital Heart Lesions*
  • Cortisone / Steroid*
  • Diabetes*
  • Emphysema*
  • Epilepsy or Seizures*
  • Fainting or Dizzy Spells*
  • Glandular Disorders*
  • Glaucoma*
  • Head / Neck Injuries*
  • Heart Disease or Attack*
  • Medical Implant*
  • Psychiatric Treatment*
  • Radiation Treatment*
  • Chemotherapy*
  • Rheumatic / Scarlet Fever*
  • Sickle Cell Disease*
  • Sinus Trouble*
  • Stomach Problems*
  • Intestinal Problems*
  • Stroke*
  • Heart Murmur*
  • Heart Pacemaker*
  • Heart Rhythm Disorder*
  • Heart Surgery*
  • Hepatitis A*
  • Hepatitis B*
  • Hepatitis C*
  • Herpes*
  • High / Low Blood Pressure*
  • Sleep Apnea*
  • Thyroid Disease*
  • Tuberculosis*
  • Ulcers*
  • Snoring*
  • Other*

  • Has the CHILD PATIENT recently had any of the following? (include approximate date)

  • Measles*
  • Approximate Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mumps*
  • Approximate Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chicken Pox*
  • Approximate Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Strep Throat*
  • Approximate Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Tonsillitis*
  • Approximate Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other*

  • WOMEN ONLY

  • Are you pregnant or suspect you may be?*
  • If yes, what is the expected delivery date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you taking any birth control pills?*
  • Do you currently have, or had in the past, any disease, condition, or problem not listed above?*
  • Is there anything else about your health we should be made aware of?*
  • Do you with to speak to the Doctor privately about any problem or medical condition?*

  • NOTE: IT IS IMPORTANT THAT ANY CHANGE IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE

  • HOW OUR OFFICE COLLECTS, USES, AND DISCLOSES PATIENTPERSONAL 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 assess 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 relationship to oral and maxillofacial complex and dental
      care generally.

    • To communicate with other treating health-care providers, including specialists and general dentists who are the
      referring dentist’s and/or peripheral dentists.

    • To allow us to maintain communication and contact with you to distribute health-care information and to book
      and confirm appointments.

    • To allow us to efficiently follow up for treatment, care, and billing.

    • For teaching and demonstrating purposes on an anonymous basis

    • To complete and submit dental claims for the third party adjudication and payment.

    • To comply with legal and regulatory requirements, including 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 Professions Act

    • To comply with agreements / undertaking entered into voluntarily by the member with the Royal College of
      Dental Surgeons of Ontario, including the delivery and/or review of patient's charts and records to the college
      in a timely fashion for regulatory and monitoring purposes

    • To permit potential purchasers, practice brokers or advisors to evaluate the dental practice.

    • To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for practice sale.

    • To deliver your charts and records to the dentist’s insurance carrier to enable insurance company to assess
      liability and quantify damages if any

    • To prepare materials for the Health Professions 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 all regulatory requirements.

    • To comply generally with the law.

  • By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to this collection, use and/or disclosure of 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

    Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.

    Our office will not, under any conditions, supply your insurer with your confidential medical history. In the even this kind of request is made, we will forward the information directly to you for review and for your specific consent. When unusual 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 withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.

  • PATIENTS CONSENT

  • I have received the above information that explains how your office will use my personal information and the steps your
    the office is taking to protect my information.

    I know that your office has a Privacy Code, and I can ask to see the Code at any time.

    I agree that Humber Valley Dental can collect, use, and disclose Personal information about

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: