• NEW PATIENT FORM

    7777 WESTON RD. SUITE 218, WOODBRIDGE, ON L4L 0G9

  • PERSONAL INFORMATION

  • Gender*
  • DATE OF BIRTH:*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • HOW DID YOU HEAR ABOUT US?*
  • Format: (000) 000-0000.

  • INSURANCE

    If you do not have dental insurance or if you prefer to provide this information over phone or in person, skip to the next section.

  • PRIMARY BENEFIT INFORMATION

  • DATE OF BIRTH:
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  • SECONDARY BENEFIT INFORMATION

  • DATE OF BIRTH:
     / /

  • DENTAL HISTORY

    Please complete this section to the best of your ability. If you cannot recall exact dates, include estimates.
  • REASON FOR TODAY'S VISIT:*
  • DATE OF LAST DENTAL VISIT:
     - -
  • LAST CLEANING:
     - -
  • LAST X-RAYS:
     - -
  • DO YOU HAVE ANXIETY WITH DENTAL TREATMENT?*
  • DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY.
  • HAVE YOU EVER BEEN ADVISED TO TAKE ANTIBIOTICS BEFORE A DENTAL APPOINTMENT?*
  • ARE YOU COMPLETELY HAPPY WITH THE SHAPE, COLOUR AND POSITION OF YOUR TEETH?*

  • MEDICAL HISTORY

  • DO YOU HAVE A PRIMARY PHYSICIAN?*
  • LAST EXAM DATE:
     - -
  • WERE ANY PROBLEMS IDENTIFIED?
  • DO YOU SMOKE / CHEW TOBACCO OR VAPE?*
  • DO YOU DRINK ALCOHOL?*
  • DO YOU USE CANNABIS OR OTHER RECREATIONAL DRUGS?*
  • ARE YOU PREGNANT OR SUSPECT YOU MAY BE?*
  • DOES YOUR FAMILY HAVE HISTORY OF CANCER, HEART DISEASE OR DIABETES?*
  • HAVE YOU EXPERIENCED COMPLICATIONS FOLLOWING A MEDICAL OR DENTAL PROCEDURE?*
  • DO YOU TAKE MEDICATION FOR OSTEOPOROSIS?*
  • HAVE YOU EVER HAD RADIATION TREATMENT TO THE HEAD OR NECK REGION?*
  • PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU:

  • CONSENT FORMS

  • CONSENT TO MEDICAL HISTORY AND CONSULTATION

  • I hereby state that the above information is, to the best of my knowledge, accurate and complete. If I ever have any change in My health, or if my medicines change, I will inform the doctor without fail, if deemed advisable. I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. I grant permission for my physician, other healthcare providers and my insurance involved in my treatment to be contacted by Dr. Rachel Kitsopanidi and staff for details and advice. I further authorize the taking of radiographs or other diagnostic measures appropriate for a thorough evaluation.

  • Date:*
     - -

  • CONSENT TO THE COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

  • I hereby acknowledge that a copy of this office's Policy of Collection, Use and Disclosure of Personal Information has been made readily accessible to me. I have been given the opportunity to review this notice and ask any questions I may have. My signature below signifies that I understand how your office will use my personal information, and the steps your office is taking to protect my information. I agree that Dr. Rachel Kitsopanidi and staff can collect, use and disclose personal information about me as set out in the information about the office's privacy policies.

  • Date:*
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  • APPOINTMENT POLICY

  • When you make an appointment with our office, we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you. Our office policy states that patients must give us 2 business days (48 hours) notice if they cannot keep an appointment. Appointment changes with less than 48 hours' notice are subject to a $50.00 service fee.

    It is my responsibility to confirm appointments, and I understand that if I do not confirm my appointment, there is a risk of the appointment being rescheduled. Patients that do not show up for their appointments may not be booked again.

  • Date:*
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  • CONSENT TO THE MEDIA RELEASE OF PATIENT PHOTOS

  • I hereby authorize Dr. Rachel Kitsopanidi or any of their assignees to take photographs, slides, and videos of my teeth, jaws, and face. I understand that my photos may be used in social media posts (Instagram and Facebook), company website gallery, and in educational publications/lectures/convention for case presentations. I do not expect compensation, financial or otherwise, for the use of these photographs.

  • Date:*
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  • Should be Empty: