1 New Patient Registration Form2 Do You Have Insurance Insurance Coverage?3 Assignment of Benefits and Payment Policy4 Medical History5 Dental History6 Personal Information Consent Form Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Sex*MaleFemaleHome Phone*Work PhoneCell PhonePrefered Contact*HOME / WORK / CELLPATIENT’S MAILING ADDRESS* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe E-MAIL ADDRESS* PATIENT’S GUARDIAN (IF UNDER 18)NameHome PhoneWork PhonePERSON WE CAN CONTACT IN CASE OF AN EMERGENCY(OTHER THAN YOUR FAMILY HOME)Name*Home Phone / Cell Phone*Work PhoneIF THIS IS YOUR FIRST VISIT, HOW DID YOU HEAR ABOUT OUR OFFICE?Referred by another personOther Primary Coverage InsurancePrimary Coverage Insurance Co. NameSubscriber NameDate of Birth Date Format: DD slash MM slash YYYY Certificate/Policy #Subscriber IDSecondary Coverage InsuranceSecondary Coverage Insurance Co. NameSubscriber NameDate of Birth Date Format: DD slash MM slash YYYY Certificate/Policy #Subscriber ID This office is willing to accept direct payment from your dental plan only If your plan allows for assignment of benefits, for the cost of those dental services which we may provide. Dental plans in the marketplace today are too numerous and varied to allow us to know the details of all of them. Your particular dental plan may or may not cover the full extent of the costs you incur for your dental treatment. This can occur because the fees in our office are based on factors which may not have been considered by your insurance carrier. Furthermore, there may be certain procedures performed which are not covered through your dental plan. These factors are beyond our control. PLEASE REVIEW YOUR DENTAL PLAN VERY CAREFULLY TO ENSURE YOU UNDERSTAND THE EXCLUSIONS AND LIMITATIONS OF YOUR PLAN. IF YOUR DENTAL PLAN DOES NOT COVER THE FULL COST OF TREATMENT, YOU WILL BE RESPONSIBLE FOR ANY DIFFERENCE BETWEEN THE AMOUNT PAID BY YOUR PLAN AND THE AMOUNT CHARGED FOR YOUR TREATMENT. Payment for dental services is expected when treatment is rendered. You will be informed of your payment or co-pay responsibility at the time treatment is completed so that you may make payment at that visit. A 2% service charge will be applied to all account balances outstanding for more than 30 days. I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for any claim. I authorize that the doctor can use my records if he/she so determines. I certify that I have read or had read to me the contents of this form, filled in completely and accurately to the best of my knowledge and do realize the risks and limitations involved. Patient/Guardian Signature*Date* Date Format: DD slash MM slash YYYY Physician*(Medical Doctor) / and their specialtyMost recent physical examination*Purpose*What is your estimate of your general health?*ExcellentGoodFairPoorSpecify illness/injury that required hospitalizationAll Allergies – SpecifyDescribe any current medical treatment, impending surgery, other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)Current MedicationsInclude supplements, vitamins and recreational; all may affect your dental treatment.DrugPurpose Check Medical Conditions that Apply Heart Attack Endocarditis Heart Valve Replacement Cardiac Stent Pacemaker Angina COPD/Lung Disease Asthma Bronchitis/Pneumonia Emphysema Sleep Apnea Sinusitis/Sinus Obstruction Tuberculosis Rheumatic/Scarlet Fever Measles Chicken pox Kidney Disease Liver Disease Jaundice Thyroid Hormone Deficiency Anemia/Blood disorder Bleeding Disorder INR>3.5 Diabetes HbA1c High Cholesterol High/Low Blood Pressure Fainting Stroke Tumor Radiation Therapy Chemotherapy Immunosuppressive Therapy Stomach/duodenal Ulcer Hernia Acid Reflux Celiac’s/digestive disorders Arthritis Rheumatoid Arthritis Osteoporosis/Osteopenia Lupus HIV/AIDS Head/Neck Injuries Migraines Epilepsy Down Syndrome Autism ADD/ADHD Anxiety Depression Fibromyalgia Psychiatric Disorders Neurological Disorders Glaucoma Others not listed Are You ?Presently being treated for any other illness?*YesNoAware of a change in your health in the last 24 Hour?*(i.e. fever, chells, new cough, diarrhea)YesNoOften exhausted or fatigued?*YesNoExperiencing frequent headaches?*YesNoA smoker or previous smoker, vaper, or use smokeless tobacco?*YesNoFEMALE – Pregnant ?YesNoPregnancy Due Date: Date Format: DD slash MM slash YYYY MALE – Prostrate disorders ?YesNo How would you rate the condition of your mouth?*ExcellentGoodFairPoorPrevious DentistHow long have you been a patient?Months/Years (ex: 02/08)Date of most recent dental exam Date Format: DD slash MM slash YYYY Date of most recent X-rays Date Format: DD slash MM slash YYYY Date of most recent treatment(other than a cleaning) Date Format: DD slash MM slash YYYY I routinely see my dentist every:*3 Months4 Months6 Months12 MonthsNot routinelyWHAT IS YOUR IMMEDIATE CONCERN?PLEASE ANSWER YES OR NO TO THE FOLLOWINGWhat is your Chief Dental Complaint?*Are you fearful of dental treatment?*YesNoHow fearful, on a scale of 1 (least) to 10 (most)*Have you had an unfavorable dental experience?*YesNoHave you ever had complications from past dental treatment?*YesNoHave you ever had trouble getting numb or had any reactions to local anesthetic?*YesNoDid you ever have braces, orthodontic treatment or had your bite adjusted?*YesNoHave you had any teeth removed?*YesNoGUM AND BONEDo your gums bleed or are they painful when brushing or flossing?*YesNoHave you ever been treated for gum disease or been told you have lost bone around your teeth?*YesNoHave you ever noticed an unpleasant taste or odor in your mouth?*YesNoIs there anyone with a history of periodontal disease in your family?*YesNoHave you ever experienced gum recession?*YesNoHave you ever had any teeth become loose, without an injury, or do you have difficulty eating an apple?*YesNoDoes the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?*YesNoHave you experienced a burning sensation in your mouth?*YesNoTOOTH STRUCTUREHave you had any cavities within the past 3 years?*YesNoDo you feel or notice any holes (i.e. pitting, craters) in your teeth or grooves along the gum line?*YesNoAre any teeth sensitive to hot, cold, biting, sweets?*YesNoDo you avoid brushing any part of your mouth due to discomfort?*YesNoHave you ever broken teeth, chipped teeth, or had a toothache or cracked filling?*YesNoDo you frequently get food caught between any teeth?*YesNoBITE AND JAW JOINTDo you have problems with your jaw joint?*(pain, sounds, limited opening, locking, popping)YesNoDo you feel like your lower jaw is being pushed back when you bite your teeth together?*YesNoDo you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard foods?*YesNoHave your teeth changed in the last 5 years, become shorter, thinner or worn?*YesNoAre your teeth crowding or developing spaces?*YesNoDo you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*YesNoDo you clench your teeth in the daytime/nighttime?*YesNoDo you wear or have you ever worn a bite appliance?*YesNoSMILE CHARACTERISTICSIs there anything about the appearance of your teeth that you would like to change?*YesNoHave you ever whitened (bleached) your teeth?*YesNoHave you felt uncomfortable or self-conscious about the appearance of your teeth?*YesNoHave you been disappointed with the appearance of previous dental work?*YesNoPatient/Guardian Signature*Date* Date Format: DD slash MM slash YYYY 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 described 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 and/or work telephone numbers, and email 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 and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process credit card payments, or to collect unpaid accounts. To process claims for payment or reimbursement from third-party benefit providers, insurance companies and government agencies. To send reminders to patients concerning the need for further dental examination or treatment. To send patients informational material about our dental practice. 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 make arrangements for the payment of dental services from whoever has been written as financially responsible for the account. 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. Patient’s Medical Information that is disclosed: To other dentists, dental specialists, health care providers and physicians, where further information and/or discussion is required or a where a patient has been referred to or from for treatment. Seeking and/or providing information to the following: Laboratories, Radiology Centres, Hospitals, etc. To include the following when necessary, such as: videos, pictures, slides, etc., for educational purposes. 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 the prospective purchaser safeguards all personal information. Dentists are regulated by the Royal College of Dental Surgeons of Ontario, which may inspect our records and interview our staff as part of its regulatory activities in the public interests. I consent to the collection, use and disclosure of my personal information as set out above.Patient/Guardian Signature*Date* Date Format: DD slash MM slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.