WELCOME TO MIDTOWN DENTAL CENTRE

The following information is required by the dentist to assist in proper diagnosis and treatment.

Todays date

ADULT PATIENT or PARENT / GUARDIAN (if child see below)

Are you the:


Name:

Address:

Date of Birth:

How did you hear about us?


Address:

CHILD or ADULT UNDER GUARDIANSHIP (IF PATIENT)

Name:

Address (if different than above)

Date of Birth

Spouse

Where may we contact you?

Where may we contact you?

PERSON RESPONSIBLE FOR ACCOUNT:

Method of payment

(Personal cheques not accepted)

Where may we contact you?

PRIMARY DENTAL INSURANCE


DATE OF BIRTH

SECONDARY DENTAL INSURANCE

DATE OF BIRTH

MEDICAL HISTORY AND DENTAL HISTORY

2. Are you being treated for any medical condition now or within the last year

3. Have you had a medical checkup within the past one year

4. Has there been a change in your general health in the past year or two

5. Are you taking any medication, non-prescription drugs or vitamins/herbals of any kind?

6. Do you have allergies? (eg. asthma, hay fever, food allergies, latex/rubber)

7. Have you ever had a peculiar or adverse reaction to any medicines or injections? (Penicillin local anaesthetic / freezing aspirin sulphonamide)

8. Do you have or have you had ANY heart, blood pressure or cholesterol problems/surgeries?

9. Do you have or have you had ANY implants or joint replacements

10. Have you had congenital heart disease, infectious endocarditis or heart transplants/surgeries?

11. Have you ever had hepatitis, jaundice or liver disease, or had known contact with a person with any of these conditions?

12. Have you ever been told that you should not give blood OR have you ever had a blood transfusion?

13. Do you have any condition that could affect your immune system? (eg. AIDS, HIV, Leukemia, Cancer)

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

15. Have you ever been hospitalized for any illnesses or operations?

16. Do YOU HAVE or HAVE YOU EVER had any of the following?

17. Are there any conditions or diseases not listed above that you have or have had?

18. Are there any diseases or medical problems that run in your family?

19. Have you ever or do you now smoke, use tobacco, Vape or ANY other products?

20. Do you wear glasses or contact lenses?

22. What do you use to clean your teeth?

23. Do your gums bleed spontaneously or when brushing or flossing?

24. Are any of your teeth sensitive to:

25. Does your jaw crack or pop when you open widely?

26. Do you grind day/night or clench your jaw day/night, neck tension?

28.Have you had or are you interested in:

30. Do you have any concerns about your dental visit?

31. Are you pregnant or suspect you may be

32. Are you taking contraceptives

INFORMED CONSENT / GENERAL RELEASE

I the undersigned, certify that I have provided an accurate and complete personal and medical / dental history and have not knowingly omitted any information. I have had the opportunity to ask questions regarding my medical / dental history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for all fees associated with these services. I give this office consent to contact me via email or phone for appointments and newsletters.

Financial Policies:

In our conlinued commitment to provide lhe highest quality dental care to all of our patients and to make those services comfortably affordable, we are pleased to offer you these payment options.
We will, as a courtesy, process your insurance benefits in our office, which will relieve you of this time consuming and sometimes complicated task.

We are committed to support you in understanding your dental health, so that you will always be able to make thc best choices.

I agree that I am fully responsible for the total payment of all procedures performed in this office - this includes any treatment that is not a benefit of any dental insurance that I may have.

Cancellation Policy:

Appointments times are reserved especially for you. lf you come in late, the Doctor may request that you reschedule the appointment and you may be charged a fee of $75. lf for any reason you should need to change your appointment, there will be no charge, provided you give us 2 business days notice. lf an appointment is cancelled with less that 48 hrs, a potential fee of $75 per 1/2 hr for hygiene and $150 per 1/2 hr for Doctor may be applied to your account. We are here to assist you in any way possible. Please make your questions and concerns know to our team. Our goal is to ensure that you have an outstanding experience.

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 below how our office is collecting, using and disclosing your personal information.
This office will collect, use and disclose information about you for the following purposes:

➔ To assess your health needs and provide safe and efficient dental care.
➔ To enable us to contact and maintain communication with you to distribute health-care infonnation and to book and confim appointments.
➔ To communicate with other treating health-care providers, including other dentists, physicians, pharmacists and lab technicians.
➔ 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.
➔ To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, as necessary.
➔ To invoice for goods and services.
➔ To process credit card payments.
➔ To collect unpaid accounts.
Thank you for your support and understanding in helping our office to comply with all regulatory requirements, and generally with the law.

I have read and understand the Privacy Police Statement:

Your appointment will have a PPE fee of $10 for non-aerosol treatments and $20 for aerosol treatments.

E-Signature

Please sign electronically below.

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