New Patient Form

New Patient Form
Name: (Mr./Miss/Mrs./Ms./Dr.)*

PrefixFirst NameLast Name
Date Of Birth

MonthDayYear
Home Tel. No:
Address (Home):
Email Address:
Cellular Phone Number:
Business Tel. No.:
Employer:
Who referred you to our office?
INSURANCE:
Insurance Company Name:
Policy No.:
Cert. or ID #
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
Name
Relationship:
Daytime Tel. No.:
Name of Family Doctor:
Tel. No. or Address:
(1) Name of Medical Specialist:
Area of Specialty:
Tel. No. or Address:
(2) Name of Medical Specialist:
Area of Specialty:
Tel. No. or Address:
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past year?

YesNoNot sure/Maybe
If so, why?
2. When was your last medical checkup? field.
3. Has there been any change in your general health in the past year?

YesNoNot sure/Maybe
If yes, please explain.
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

YesNosure/Maybe
If yes, please list.
5. Do you have any allergies?

YesNoNot sure/Maybe
If yes, please explain.
6. Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNoNot sure/Maybe
7. Do you have or have you ever had asthma?

YesNoNot sure/Maybe
8. Do you have or have you ever had any heart or blood pressure problems?

YesNoNot sure/Maybe
9. Do you have or have you ever had a replacement or repair of a heart valve, aninfection of the heart (i.e. infective endocarditis), a heart condition from birth{i.e. congenital heart disease) or a heart transplant?

YesNoNot sure/Maybe
10. Do you have a prosthetic or artificial joint?

YesNoNot sure/Maybe
11. Do you have any conditions or therapies that could affect your immune system,e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

YesNoNot sure/Maybe
12. Have you ever had hepatitis, jaundice or liver disease?

YesNoNot sure/Maybe
13. Do you have a bleeding problem or bleeding disorder?

YesNoNot sure/Maybe
14. Have you ever been hospitalized for any illnesses or operations?

YesNoNot sure/Maybe
If yes, please explain.
15. Do you have or have you ever had any of the following? Please check.

chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)osteoporosisheart attackmitral valveNot sure/Maybelung diseasediabeteskidney disease medicationsstroke prolapsetuberculosisstomach ulcersthyroid disease Fosamax, Actonelshortness of breathheart murmurcancerarthritisdrug/alcohol
16. Are there any conditions or diseases not listed above that you have or have had?

YesNoNot sure/Maybe
If so, what?
17. Are there any diseases or medical problems that run in your family?(e.g. diabetes, cancer or heart disease)

YesNoNot sure/Maybe
18. Do you smoke or chew tobacco products?

YesNoNot sure/Maybe
19. Are you nervous during dental treatment?

YesType option 2Not sure/Maybe
20. For women only: Are you breastfeeding or pregnant?

YesNoNot sure/Maybe
If pregnant, what is the expected delivery date?

MonthDayYear
Date
To the best of my knowledge, the above information is correct.
Patient/Parent/Guardian Signature:

Clear
Date

MonthDayYear
Date
Dentist Signature:

Clear
Date

MonthDayYear
Date
DENTISTS NOTES:
LAKESIDE FAMILY
Privacy of your personal health information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients.

In this office, Dr. Michael Cohen is the contact person for personal health information related matters.

All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Attached to this consent form, we have outlined what our office is doing to ensure that:
- only necessary information is collected about you;
- we only share your information with your consent;
- storage, retention and destruction of your personal health information complies with existing legislation and privacy protection protocols;
- our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with me or any member of our office staff
HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENTS' PERSONAL HEALTH INFORMATION

Our office understands the importance of protecting your personal health 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 personal health 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 the 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 dentists 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 third party adjudication and payment
- to comply with legal and regulatory requirements, including the 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/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients' charts and records to the College in a timely fashion for regulatory and monitoring purposes
- to deliver your charts and records to the dentist's insurance carrier to enable the 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 the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance. Your personal health 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.
You may withdraw your consent for use or disclosure of your personal health information at any time.
PATIENT CONSENT:
I have reviewed the information that explains how your office will use my personal health information and the steps your office is taking to protect my information.
I agree that Dr. Michael Cohen Dentistry Professional Corporation can collect, use and disclose personal health information about
[Patient Name]
as set out above in the information about the office’s privacy policies.
Signature PatientGuardian

Clear
Date

MonthDayYear
Date
We welcome you and your family to Lakeside Family Dental and look forward to providing you with quality dental care. To provide you with the most beneficial and comprehensive service and care, we request you to review and sign our office financial policy consent form. Please know, we are always available to answer any questions you may have regarding proposed treatment and payment options.

What our patients without dental insurance need to know:
- Payment for dental services is due and payable at the time of treatment unless pre- arrangements have been made with our office.
What our patients with dental insurance need to know:
- Your treatment plan is individually tailored to your needs and wants, not based on your dental insurance benefits.
- Not all services are benefits in all insurance contracts; however, we will always do our best to help you utilize your insurance benefits.
- Your dental insurance policy is a contract between you, your employer and your insurance company and it is your responsibility to thoroughly understand the benefits and exceptions of your particular policy.
- Our team is trained to help you with questions you may have relating to how your claim was filed, or regarding any additional information your carrier may need to process your claim. Please, ask if you have any questions.
- As a courtesy to all of our insured patients, we will file your dental insurance claim forms. You are responsible at the time of treatment for payment to us of any applicable deductible and for your co-insurance portion.
- Your claim will be filed immediately, and benefits are expected to be paid within 7 - 14 days.
- Payment options available: cash, debit, MasterCard, Visa.
- Extended payment options are available on a case specific basis when pre-arranged with our office and can be discussed with our Financial Coordinator.
LAKESIDEFAMILY DENTAL
I agree to pay for all treatment in a timely fashion as described.

Refund Policy

All payments collected on date of service may be refunded same day. "Refund Requests" after date of service will be processed within 15 days of the refund submission form. Please note ALL PENDING INSURANCE CLAIMS must be paid by your insurance company before a refund may be made.

(For patients with dental insurance who would prefer their insurance company to send payment to the office.)
I,
hereby authorize my insurance benefits to be paid directly to Lakeside Family Dental. I realize that I am responsible to pay any deductible amount(s), my co-insurance portion and any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.
Patient/Legal Guardian
Date

MonthDayYear
Date
Staff Initials
(905) 637-0801 Lakeside Shopping Village 5353 Lakeshore Road, Unit 21info@lakesidefamilydental.ca www.lakesidefamilydental.ca Burlington, Ontario L7L 1C8
Should be Empty:

LAKESIDE FAMILY

LAKESIDEFAMILY DENTAL