www.humbervalleydental.com - New Patient Form Logo

  • 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

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  • MEDICAL PRIORITY

  • EMERGENCY CONTACT

  • FINANCIAL INFORMATION

  • DENTAL HISTORY

    Please check Yes or No to each question. If unsure of question, please consult with dentist.
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  • Have you ever had any of the following?

  • Have you ever experienced any of the following jaw problems

  • Do you have any of the following habits?

  • HEALTH HISTORY

    Please check Yes or No to each question. If unsure of question, please consult with dentist.
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  • Have you ever reacted adversely to any of the following: (please select)

  • Do you have any of the following?

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

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

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  • WOMEN ONLY

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  • 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

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