(Los Gatos) Current Patient Update Form

  • Existing Patient Health Update

    So we can ensure that we can provide you with the best care possible, please fill out the following private and secure HIPAA compliant form to the best of your abilities. Please contact our office if you would prefer a paper form.

  • Patient Information

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  • In case of Emergency

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  • Are you being treated by your GP or a Specialist at the moment?*

  • Your Medical History

  • Please tick to indicate that you have had the following conditions*

  • Do you have any other medical conditions not listed above?*
  • Do you smoke cigarettes?*
  • Do you smoke marijuana?*
  • Do you enjoy other recreational drugs?*
  • Has your GP or Specialist told you that you require taking antibiotics before dental treatment?*
  • Are you pregnant?
  • Do you have any allergies to

  • Do you have any adverse reactions and/or allergies to any drugs or medications not listed above?*
  • Are you taking any drugs or medications (including vitamins & herb supplements)?*
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  • Are you interested to see if we could offer any cosmetic procedures to your teeth?
  • Have you been to any other dental office or dental specialist office besides our office in the last year?*

  • Preferred Reminder Method

  • What is your preferred reminder method, when confirming your appointments?*
  • What is your preferred reminder method, when reminding your about your 6 monthly dental examinations & cleans?*

  • Privacy & Confidential Information

  • I have confidential medical information that I do not wish to write down. I would prefer to speak to the dentist about this.*
  • I have read the Privacy Policy and understood the policy.*

  • Terms & Conditions

  • Consent for Treatment:

    1. I hereby authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnotic aids deemed appropriate by the dentist to make a thorough diagnosis as mutually agree upon by me. 
    2. Upon such diagnosis, I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide the appropriate care.
    3. I agree to be responsible for payment of all services rendered on my behalf and/or on behalf of my dependants. I understand that payment is due at anytime of service unless other arrangements have been made.

     

    Payment for Treatment:

    We accept Visa, Mastercard, American Express, personal cheque and cash.

    We also can process your private health fund claim at the time of your appointment but need your card at every visit. 

     

    Cancellation Policy:

    We have a 48 hour (2 business day) cancellation policy to allow us ample time to offer your appointment to another patient in need of it. A fee may be charged for missed appointments or failure to reschedule before the 48 hour time limit. 

    I understand the consent for treatment, the payment and cancellation policies as stated above. 

    By my electronic signature below, I agree to the terms and conditions.

     

     

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health and I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. It is my responsibility to inform the dental office of any changes in medical status. 

  • Patient Photo

  • One of the patient identifiers for the National Standard is a patient photo.

    If you have a preferred photo you would like to use, please upload or take a photo of yourself on your phone for your patient file. 

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