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NEW PATIENT FORM – English

WELCOME TO BATHURST COLLEGE DENTISTRY

To serve you better, we ask that you complete the following patient form.

If assistance is needed please call 416 925-0154.

COMPLETED BY

PATIENT INFORMATION

All sections marked with an asterisk *

are mandatory to be completed.

FINANCIAL INFORMATION

Method of Payment
Person Responsible for Financials

PRIMARY CONTACT (Only complete, if different from above).

PRIMARY INSURANCE

SECONDARY INSURANCE

COMMITMENT

Dental insurance is considered a method of payment. However, the patient themselves or whomever is responsible for financials (as listed above), is required to pay all unpaid balances not covered by insurance. Initial here to confirm you agree.

Security

All information is encrypted

and confidential.

MEDICAL HISTORY

1) Are you presently under the care of a physician?
2) Have you ever been hospitalized?
3) Are you currently taking any drugs or medication?
5) Have you ever been warned against using other medications?
4) Have you ever had any adverse effects to any of the following:
6) Have you ever taken prolonged medical or non-medical drugs?
7) Do you suffer from any allergies (hay fever, latex, etc.)?
8) Do you bruise easily or have prolonged bleeding?
9) Do you smoke?
10) Have you ever fainted, had shortness of breath or chest pain?

11) WOMEN

11 A) Are you pregnant?
11 B) Are you using birth control?
11 C) Have you reached menopause?

Select all applicable boxes.

12 A) Do you have? Have you ever had any of the following?
12 B) Do you have? Have you ever had any of the following?

13) CHILDREN

Select all applicable boxes & enter approximate dates.

13) Have you recently had any of the following?

DENTAL HISTORY

A) What is the reason for today’s visit?
B) How frequently do you visit the dentist?
F) Do your gums bleed when:
E) Are your teeth sensitive to:
G) Do your gums feel swollen or tender?
H) Do you have bad breath or a bad taste in your mouth?
I) Do your jaws crack, pop, or grate when you open widely?
J) Do you grind or clench your teeth?
K) Does food get caught between your teeth?
L) Have you ever had local anesthetic (freezing)?
N) Have you ever had any of the following:
M) Have you ever had any problems with previous dental treatments?
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CANCELLATION FEES

 

No fee for cancellations with notice greater than 48 hours.

Cancellations under 48 hours are subject to a fee of $50 for each hour missed.

GENERAL RELEASE

I, the undersigned, understand that the information contained in the medical and dental history sections of this form are important to my treatment. I certify that all the information that I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor and/or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibilities for fees associated with my dental treatment or dental diagnostic procedures. By initialing this digital document, I consent to the collection of my personal information via an electronic device. I agree that my initials will be legally adopted as my signature and that this form is legally binding. Additionally, I agree that my typed name and initials will act as official representatives of my personal signature.

Form Completed & Authorized by:

THANK YOU for submitting the new patient form. (English Version)

SECURITY

PIPEDA & HIPAA APPROVED DATA ENCRYPTION

• Fully compliant servers, with updated compliance agreements.

• Website and email servers are powered by Microsoft end-to-end encryption.

• PIPEDA Compliant – Personal Information Protection and Electronic Documents Act (PIPEDA). CANADA

• HIPAA Compliant – Health Insurance Portability and Accountability Act (HIPAA). USA