New Patient Form

NEW PATIENT INFORMATION FORM
Personal information
Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date of birth
Phone Number (home)
Please enter a valid phone number.
Phone Number (work)
Please enter a valid phone number.
Phone Number (cell)*
Please enter a valid phone number.
Emergency contact name*

First NameLast Name
Emergency contact telephone number *
Please enter a valid phone number.
Relationship to emergency contact*
Name of primary physician*
Telephone No. of primary physician:*
Please enter a valid phone number.
Date of last visit*
How did you hear about us?*
Preferred method of contact*

PhoneEmailText
Insurance information (if applicable)
Do you have insurance coverage?*

YesNo
Primary:
Subscriber name:

First NameLast Name
Insurance company:
Policy Group Number:
Division:
Certificate Number:
Relationship to Insured:
Date of birth

MonthDayYear
Date
Secondary:
Subscriber Name:

First NameLast Name
Insurance company:
Policy Group Number:
Division:
Certificate Number:
Relationship to Insured:
Date of birth

MonthDayYear
Date
Medical History and Details
Have you been hospitalized or had a major operation within the last 2 years?*

NoYes
If you indicated “Yes”, please provide details:
Are you or could you be pregnant and/or breastfeeding?*

NoYes
If you indicated “Yes”, please provide details:
Do you have, or have you ever had, a heart condition or tested positive for a disease that could affect your immune system? (e.g. leukemia requiring chemotherapy)*

NoYes
If you indicated “Yes”, please provide details:
Please indicate which of the following you have had or have ever had:

Do you have or have you ever had any of the following? Please check those that apply.*

	Yes	No
AIDS
Anemia
Arthritis/Rheumatism
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive bleeding
Fainting
Hay Fever
Head Injuries
Hip Replacement Surgery
Kidney Disease
Knee Replacement
Liver Disease
Lung Disease
Mental Disorder
Stomach Ulcer
Stroke
Thyroid Problem
Tuberculosis
Venereal Disease
Prosthetic Heart Valve
Low blood pressure
High blood pressure
ADHD

Additional comments and/or medical conditions (current or otherwise) not listed:
Are you currently taking any prescription or non-prescription medication?*

NoYes
If you indicated “Yes”, please provide details:
Dental visits and dental history

	Yes	No
Have you ever had a dental examination with a full series of x-rays of your teeth and jaws?
Have you ever had any problems/reactions to local anaesthetic?
Tooth pain or discomfort while chewing
Are your teeth sensitive to Heat?
Are your teeth sensitive to Cold?
Are your teeth sensitive to Sweets?
Are your teeth sensitive to Other Things?
Do your gums bleed when brushing?
Do your gums bleed spontaneously?
Do your gums bleed when flossing?
Does your jaw crack, pop or grate when opened widely?
Does food lodge between your teeth?
Do you grind or clench your teeth?

Date of your last dental visit*

MonthDayYear
Date
Do you have any dental anxiety?*

YesNo
How did you hear about our office?*
Have you ever had a bad experience with a dentist? Describe your experience.
Consent

Collection of personal information
Privacy of your personal information is an important part of providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We collect personal information for the following purposes and mandate:

• Only necessary information is collected about you;

• We only collect, use, and share your information with your consent;

• Storage, retention and destruction of your personal information complies with existing legislation;

• We continuously review our policies and privacy protection protocols on an ongoing, annual basis to ensure that we comply with our obligations under various provincial legislation;

• We confirm that our privacy protocols comply with provincial privacy legislation and standards of our provincial regulatory body, as amended from time to time.

This office will collect, use and disclose information about you for the following purposes, including:

• To deliver safe and efficient patient care and to identify and to ensure continuous high-quality service.

• To assess your health and dental care needs and to advise you of treatment options

• To enable us to contact you and to establish and maintain communication with you.

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

• To maintain communication with you to provide health care information and to book/confirm appointments.

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

• To comply with legal and regulatory requirements, including the delivery of patients' charts and records to our provincial regulatory body, in a timely fashion.

• To invoice for goods and services and to process credit card payments.

•To comply with our obligations under applicable federal and provincial privacy legislation.

By signing the consent section of this Patient Consent Form below, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes included herein. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Our office will not, under any conditions, supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly for your review, and for your specific consent. I have reviewed the above information that explains how your office will use and protect my personal information. I understand that I may withdraw my consent at any time, and, should I wish to do so, I will contact the clinic to inform them of this intention. I agree that my dental clinic or dental care provider, as outlined herein, can collect, use and disclose personal information for the purposes set out herein.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Please use your mouse or finger to sign below. *

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Office policy
We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to be paid for at each visit as they are performed.

Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A $50.00 fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.
By signing below, I authorize Lakeview Village Dentistry to perform all dental or diagnostic procedures agreed to be necessary or advisable, including x-rays, photographs, and the use of local anaesthetic or other medications as indicated. I understand that if I miss an appointment or provide less than 48 hours notice to cancel or reschedule an appointment, I may be charged a cancellation fee. I assume full responsibility for fees associated with my dental treatment and those of my dependents. I have read and fully understand the above conditions of treatment and I accept my responsibility as a patient at this office.*

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Date*

MonthDayYear
Date
Should be Empty:

NEW PATIENT INFORMATION FORM

Personal information

Insurance information (if applicable)

Primary:

Secondary:

Medical History and Details

Please indicate which of the following you have had or have ever had:

Dental visits and dental history

Consent

Office policy