New Patient Medical History Form - Dr. Yi Jin Dentistry

Name:

First NameMiddle NameLast Name

Prefers to be called:

Gender:

Other

Date of Birth:

Date

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone (Home):

Please enter a valid phone number.Format: (000) 000-0000.

Phone (Cell):

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Occupation:

Name:

First NameLast Name

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Relation to you:

Name:

First NameLast Name

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Address:

Name:

First NameLast Name

Area of Specialty:

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Address:

Name of Insured:

Relationship to Patient:

Group Policy No.

Max. Annual Benefit:

Deductible:

Date of Birth of Insured:

Date

Insurance Company:

Certificate No.

Percentage Covered:

How much have you used?

Name of Insured:

Relationship to Patient:

Group Policy No.

Max. Annual Benefit:

Deductible:

Date of Birth of Insured:

Date

Insurance Company:

Certificate No.

Percentage Covered:

How much have you used?

I authorize the release to my dental benefits plan administrator the information contained in claims submitted electronically and the communication of information related to the coverage of services described to the named dentist. I hereby assign my benefits, payable from electronically submitted claims, to Dr. Yi Jin and authorize payment to her directly if my insurance allows.

Patient signature:

Print name:

Date:

Date

Are you being treated for any medical condition at the present or have been treated within the past year? If so, why?

Not Sure/Maybe

When was your last medical checkup? Please provide a reason:

Are you taking any medications, non-prescription drugs, or herbal supplements? If yes, please list.

Not Sure/Maybe

Do you have any allergies (esp. Latex, rubber, antibiotics)? If yes, please list.

Not Sure/Maybe

Have you ever had any peculiar or adverse reaction to medications or injections? If yes, please explain.

Not Sure/Maybe

Do you have or have you ever had asthma?

Not Sure/Maybe

Do you have or have you ever had any heart or blood pressure problems?

Not Sure/Maybe

Do you have or have you ever had an artificial heart valve, an infection of the heart, a heart condition from birth (congenital heart disease), or a heart transplant?

Not Sure/Maybe

Do you have a prosthetic or artificial joint?

Not Sure/Maybe

Do you have any conditions that could affect your immune system (ex. leukemia, HIV/AIDS, radiotherapy/chemotherapy)?

Not Sure/Maybe

Have you ever had hepatitis, jaundice, or liver disease?

Not Sure/Maybe

Do you have a tendency to bleed or bruise easily for a prolonged period of time after a cut?

Not Sure/Maybe

Have you ever been hospitalized for any illnesses or operations? If yes, please explain.

Not Sure/Maybe

Are there any conditions or diseases not listed above that you have or have had? If so, what?

Not Sure/Maybe

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

Are there any diseases or medical problems that run in your family? (Diabetes, cancer, heart disease, etc.)

Not Sure/Maybe

Do you smoke or chew tobacco? If yes, packs/day x years.

How nervous are you for dental treatment?

For women only: Are you breastfeeding?

Pregnant?

If yes, which trimester are you in?

Are you on birth control?

If yes, what type?

To the best of my knowledge, the above information is correct, and this form has been reviewed with me by my dentist. I have been informed that my physician may be contacted by letter, fax, or phone to complete details of my medical history, and that I consent to allowing my physician to release such information to ensure the safety of my dental treatment.

Patient/parent/guardian signature:

Print name:

Date:

Date

Dentist signature:

Date:

Date

Privacy of your personal information is an important part of our office protocol to provide you with quality dental care. We understand the importance of protecting your personal information. We are faithful in collecting, using, and disclosing your personal information responsibly. We also try to be as open and clear as possible about the way we handle your personal information. It is important to us to provide this service to our patients. In this office, Dr. Yi Jin acts as the Privacy Information Officer. All staff members who come in contact with your personal 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 the necessary information is collected about you
We only share your information with your consent
Storage, retention, and destruction of your personal information complies with existing legislation and privacy protection protocols
Our privacy protocols comply with privacy legislation, stands of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the Federal law.

Please be assured that every staff personnel in our office is committed to ensuring that you receive thebest quality dental care.

How Our Office Collects, Uses, and Discloses Patients' Personal 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, as necessary, 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 safe 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 physicians, 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
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 allow consultants or advisors to assist in beneficial office management processes
To deliver your charts and records to the Centre's benefits managers to assess liability and eligibility and to our satellite dental offices
To prepare materials for the Health Professions Appeal and Review Board (HPARB)
To invoice for goods and services
To process payments
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 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. Our office will not, under any conditions, supply anyone with your confidential medical history. In the event 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 lease is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the outcomes of that decision and the process.

Patient Consent

I have reviewed the above information that explains how the office of Dr. Yi Jin will use my personal information and the steps the office is taking to protect my information. I know that the office has a Privacy Code, and that a copy of the Code can be provided to me upon my request. I agree that Dr. Yi Jincan collect, use, and disclose personal information about:

Patient's Name as set out above in the information about the office's privacy policy.

Signature

Print Name:

Date

Signature of Witness

MEDICAL HISTORY QUESTIONNAIRE

PATIENT INFORMATION

Emergency Contact

Family Doctor

Specialist (if any)

INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

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. Please fill in the entire form. Thank you!

Patient Privacy Consent Form