New Patient Form

New Patient Form
Name

First NameLast Name
Preferred Name
Gender
Date of Birth

DayMonthYear
Date
Marital Status
Address

ADDRESS:

Street Address Line 2

CITYPROV

POSTAL CODE:
ADDRESS
CITY
PROV
POSTAL CODE
CELL PHONE
(This number will be used for confirmation of appointments)
Email
example@example.com
(Email will be used for electronic communication)
EMERGENCY CONTACT NAME
RELATION
PHONE
PREFERRED METHOD OF CONTACT

CELL PHONEEMAIL
How did you hear about us? (Please select one)

GoogleFacebookInstagramFlyerWalk-InCommunity NewsletterFriend/Family member/ Co-workerOther
Friend/Family member/ Co-worker
Other
DENTAL QUESTIONNAIRE
Previous dentist name or dental office
When was your last dental visit:

6 months1 year2 years3 years +
When were your last x-rays taken:

6 months1 year2 years3 years +
When was your last dental cleaning:

6 months1 year2 years3 years +
Are you currently in any discomfort/pain with your teeth or gums?

YESNO
Do your gums ever bleed?

YESNO
Have you ever fainted or had complications following dental treatment?

YESNO
Have you ever had an injury, surgery, or x-ray therapy to the face or jaw?

YESNO
Do you have any pain in your jaw?

YESNO
Do you clench or grind your teeth?

YESNO
Would you like to have straighter teeth?

YESNO
Are you interested in having ZOOM Whitening treatment?

YESNO
Nervous or anxious about dental treatment?

YESNO
Desired outcomes after dental treatment
MEDICAL QUESTIONNAIRE

(Please check all that apply to you)
AIDS/HIVGLAUCOMARADIATION TREATMENTALCOHOL OR DRUG USEGROWTH OR TUMORSRESPIRATORY PROBLEMSANEMIAHEAD INJURYRHEUMATIC FEVERARTHRITISHEART DISEASESINUS PROBLEMARTIFICIAL VALVES/JOINTSHEART MURMURHIGH CHOLESTEROLASTHMA (INHALER Y/N)HEPATITIS (TYPE: )STD/ VENEREAL DISEASEBLOOD DISORDERBLOOD PRESSURESTOMACH PROBLEMSCANCER/ CHEMOTHERAPYJAUNDICESTROKEDIABETES (INSULIN Y/N)KIDNEY DISEASETHYROID DISEASEEPILEPSYLIVER DISEASETMJ PROBLEMSEXCESSIVE BLEEDINGMENTAL DISORDERTUBERCULOSISPACEMAKERANXIETYDEPRESSION
PREGNANTBREASTFEEDINGBIRTH CONTROLSMOKER/VAPEEX-SMOKERMARIJUANA/CANNABIS
Do you require PREMEDICATION such as an antibiotic for dental treatment due to a heart condition and/or artificial joints?

YESNO
Do you have ALLERGIES to?

ADVIL/MOTRINTYLENOLCODEINE/MORPHINELATEXSEASONAL
ANTIBIOTIC (please specify)
SPECIFIC FOOD
OTHER
FAMILY DOCTOR
PHONE
Clinic’s Name:
Have you been admitted to a hospital for major surgery in the last 2 years?
Please list all the medications, pills, vitamins or herbs you are presently taking:
PHARMACY NAME:
PHONE
Medication
For
Financial Policies
OPTION #1 - Full Payment at Time of Service: Full payment is due at the time of treatment and yourinsurance company reimburses you (if applicable). We accept cash, Interac, VISA or Mastercard
OPTION #2 - Direct Billing to Your Insurance: A credit card must be kept on file. Once we have receivedpayment from your insurance company, we will process the balance on your credit card. You will becontacted before your credit card is charged if the balance is over $100.00.
Your dental insurance policy is an agreement between you and your insurance company, and we will be happy to assist you in preparing and sending in the necessary forms. Please remember that no insurance company attempts to cover all dental costs. We cannot render dental treatment on the assumption that our dental fees will be paid in full by an insurance company. Full payment to our office remains your responsibility, regardless of how much your insurance does or does not pay.

If you have dental insurance, please send a PICTURE of your insurance card to 587-358- 2160 or email at info@avyanfamilydental.com.

If you are NOT the Primary Policy Holder of your insurance policy, please include the following details as well:

Primary Policy Holder Name:
Primary Policy Holder date of birth:
Primary Policy Holder address (if different from patient’s):

If you have more than one insurance policy, kindly send the same details mentioned above for both policies.

I am aware that Avyan Family Dental direct bills my insurance company as a courtesy to me and that in doing so, the dental office accepts no responsibility for any uncovered amounts, amounts over benefit maximums, limitations or plan restrictions, etc. I understand that the dental office collects my dental coverage information as a guideline only to assist me in maximizing my benefits and this does not hold them responsible for my dental account. Avyan Family Dental advises that I make myself aware of my dental plan and eligible coverage and that I ask my dental team about all procedures I am authorizing.
Initial
Avyan Family Dental advises me to contact my plan administrator or insurance company for questions regarding eligible procedures and authorization of treatment. In addition, I am advised to make myself aware of all costs involved with my dental care. Avyan Family Dental advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan.
Initial
Payment is due at the time of service. I am aware that if the dental office does not receive confirmation from my insurance for their exact payment, then Avyan Family Dental will charge the credit card I agree to leave on file when payment is paid to the office by my insurance company, whenever that date may be.
Initial
I also understand that any uncovered procedures that may have been done at another dental office are my responsibility. IMPORTANT: Please be advised that complete oral examinations (new patient exams) & xray coverage will be denied by your insurance if you have had this procedure completed at another dental office within the time limitations on your specific plan. You are responsible for this payment then in our office should this not be an eligible benefit with your coverage.
Initial
Financial Responsibility

I agree to the financial responsibility for any amounts not covered by my dental insurance to be applied to credit card below:
Credit Card (Circle one:)

VISAMASTERCARD
Card Number:
Exp:
CVC:
Name as it appears on the card:
Signature

Clear
Today’s Date:

MonthDayYear
Date
Avyan Family Dental Personal Information Consent Form – Privacy Act Information
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, home/cell telephone numbers, and e-mail addresses.
(Collectively referred to as “Contact Information”.) Contact information is collected and used for the
following purposes:
- To open and update patient files
- To invoice patients for dental services, to process credit card
- payments, or to collect unpaid accounts
- To process claims for payment or reimbursement from third party
- health benefit providers and insurance companies
- To send reminders to patients concerning the need for further dental
- examination or treatment
- To send patients informational material about our dental materials
- To follow up with treatment and/or customer services
Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf. Financial information may be collected in order to decide for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as "Medical Information".) Patients' Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients' Medical Information is disclosed for the following purposes:
- To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
- To other dentists and dental specialists where we are seeking a second opinion, and the patient has consented to us obtaining the second opinion
- To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment
- To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
- To other health care professionals, such as physicians, if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment
If we are ever considering selling all or part of our dental practice, qualified, potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

If you need to reschedule, please give our office a call at least 48 hours before the appointment to avoid any short cancellation fees of $100 as we blocked this time specially for you. Thank you for choosing Avyan Family Dental for your dental care needs
SIGNATURE OF PATIENT/GUARDIAN

Clear
PRINTED NAME
DATE

MonthDayYear
Date
Should be Empty:

DENTAL QUESTIONNAIRE

MEDICAL QUESTIONNAIRE

Financial Policies

Financial Responsibility

Avyan Family Dental Personal Information Consent Form – Privacy Act Information