In an effort to serve you better, we ask that you complete the following new patient form to the best of your ability. We will be glad to assist you with any questions you may have.

PATIENT INFORMATION

Title:

Patient Name:*

Date of Birth:*

Sex:

Address:*

Employer:
Occupation:
CONTACT INFORMATION
Emergency Contact:*
Phone Number:*
Family Doctor:
Phone Number:
REFERRAL SOURCE
How did you hear about us?

INSURANCE INFORMATION
Do you have Dental Insurance?* Yes   |   No

If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Information

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

% Coverage For:

Secondary Insurance Information (if applicable)

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

% Coverage For:


MEDICAL HISTORY - All information is Confidential

Are you presently being treated for any medical condition at the present or within the past year?

 Yes   No 
If yes, please explain why:

Was your last medical checkup within the past year?

 Yes   No 

Has there been any change in your general health in the past year?

 Yes   No 

Are you currently taking any medications or non-prescription drugs of any kind?

 Yes   No 
If yes, please list:

Have you ever been warned against using any other medications?

 Yes   No 
If yes, please list:

Have you ever taken prolonged medical or non-medical drugs?

 Yes   No 
If yes, please list:

Do you suffer from any allergies (hay fever, latex/rubber, etc)?

 Yes   No 
If yes, please list:

Allergies: Have you ever had a reaction to any of the following?*

Penicillin
Sulfonamide
Asprin
Barbiturates (sleeping pills)
Codeine
Darvon
Local Anesthetic (Freezing)
General Anesthetic
No Drug Allergies
Other (please specifiy below)

Do you or did you smoke?

 Yes   No 
If yes, for how long?

Do you drink alcoholic beverages on a regular basis?

 Yes   No 

Do you use recreational drugs? (e.g. cocain or amphetamines)

 Yes   No 

(For women only) Are you pregnant?

 Yes   No 
If yes, when is your due date?

Do you bruise easily or have prolonged bleeding?

 Yes   No 

Have you ever fainted, had shortness of breath, or chest pains?

 Yes   No 

Are you anxious during dental treatments? (Please indicate by marking the scale)

 Not at all   1   2   3   4   5   Very anxious 

If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?

 Yes   No 

Have you ever had any serious trouble with any previous dental treatment?

 Yes   No 
If yes, please describe:

Do you have or have you had any of the following conditions. Please check all that apply:*

Aids
Anemia
Angina pectoris
Anorexia nervosa
Artificial Heart Valve
Arthiritis/rheumatism
Artificial joints (hips, knees)
Asthma
Blood Disorders
Bronchitis
Bulimia
Cancer
Circulation Problems
Congenital Heart Lesions
Cortisone/steroid
Diabetes
Drug/alcohol dependence
Emphysema
Epilepsy
Glandular Disorders
Glaucoma
Head/Neck Injuries
Heart Disease/Attack
Heart Murmur
Heart Pacemaker/surgery
Heart Rhythm Disorder
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
HIV Positive
Hodgkin's Disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung Disease
Malignant Hypothermia
Mental/Nervous Disorder
Mitral Valve Prolapse
Organ Transplant/Implant
Psychiatric Disorders
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Problems
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
Other
None of the above

Is there anything else we should know about your health?


DENTAL HISTORY - All information is Confidential

Previous Dentist:

Why did you leave your last dentist?

How often do you have you teeth cleaned?  3-6 months  Annually  Other:

What is your IMMEDIATE dental concern?

Date of your last dental visit?  

Date of your last dental X-Ray?  

Please select YES or NO to the following:

1. Are you satisfied with the appearance of your teeth?

 Yes   No 

If no, please specify:

2. Did you have any unfavourable dental experiences?

 Yes   No 

3. Do you have dental fears?

 Yes   No 

4. Are you nervous about your dental treatment?

 Yes   No 

5. Problems with effectiveness or bad reactions to dental anesthetic?

 Yes   No 

6. Bleeding gums?

 Yes   No 

7. Avoid brushing any part of your mouth?

 Yes   No 

8. Sensitive to temperature? (hot or cold)

 Yes   No 

9. Does food get caught between your teeth?

 Yes   No 

10. Sore teeth?

 Yes   No 

11. Burning sensation in your mouth?

 Yes   No 

12. Difficulty swallowing?

 Yes   No 

13. An unpleasant taste or odour in your mouth?

 Yes   No 

14. Dry mouth?

 Yes   No 

15. Jaw problems (temporomandibular joint or TMJ)?

 Yes   No 

16. Stiff neck muscles?

 Yes   No 

17. Tension headaches?

 Yes   No 

18. Clench or grind your teeth?

 Yes   No 

19. Lost any teeth?

 Yes   No 

Do you have or have you had any of the following procedures? Please check all that apply:

Bridgework
Crowns or Caps
Dentures or partial dentures
Orthodontics (braces)
Periodontal (gums)
Root canal treatment
None of the above

Please elaborate if you have any of the above:

Supplemental Denture History:

If you are wearing a partial or complete artificial denture, please complete the following:

  • Has your present denture been relined? When? 
  • Is your present denture a problem? Describe: 
  • Are you satisfied with your appearance? 
  • Are you satisfied with your chewing ability? 
  • When did you receive your first partial or complete denture? 
  • How long have you worn your present denture? 

CONSENT
 I acknowledge that the information given to me is true to the best of my knowledge and that the questions have been reviewed with me. Should there be any changes to my present health status in the future, I will advise Papini Dentistry. I have been informed that my physician may be contacted by letter, email, fax, or telephone in order to complete details of my medical history. I hereby consent to my physician providing Papini Dentistry with any information in this regard which may ensure safe dental treatment. Finally, I hereby acknowledge that dental treatment may be delayed until all medical information required by Papini Dentistry is received.


Patient Name*:
Date*:
Patient Initials*:
GENERAL RELEASE
I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

PRIVACY CONSENT

For Collection Use and Disclosure Information

Privacy of a patient is an important part of our office. We understand the importance of protecting personal information. We are committed to collecting, using, and disclosing your personal information. In this office, Dr. Papini 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 you 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 necessary information is collected about you
  • We only share your information with your consent
  • Storage retention and destruction of your personal information complies with every legislation and privacy protection protocols
  • Our privacy protocols comply with privacy legislation standards of our body of the royal college of Dental Surgeons of Ontario, and the law

Do not hesitate to discuss our polices with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensure that you receive the best 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 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 asses your health needs
  • To provide 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 the relationship to the oral and maxillofacial complex and dental care generally
  • To communicate with other treating health care providers, including specialist and general dentists who are the referring dentists and/or peripheral dentists
  • To allow us to maintain communication and contract with you to distribute healthcare information and to book and confirm appointments
  • To allow us to efficiently follow-up with treatment care and billing
  • For teaching and demonstrating purposes on an anonymous basis
  • To complete and submit dental claims for third party adjunction 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 protection act.
  • To comply with agreements/undertakings entered 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 permit potential purchasers, practice brokers of advisors to evaluate the dental practice
  • To allow the potential purchasers, practice brokers or advisors to conduct in preparation for a practice sale
  • To deliver your charts and records to the dentist's insurance carrier to enable the insurance company to asses liability and quantity changes, if any
  • To prepare materials for the Health Professionals Appeal and Review Board (HPARB)
  • To invoice for goods and services
  • To process credit card payments
  • To collect unpaid accounts
  • To assist this office to comply with the regulatory requirements
  • To comply generally with the law

By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection use and/or disclosures or 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. You information might be accessed by the regulatory authorized under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling it's manors under the RHPA, and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medial history. In this event, at this time, where a request is made, we will forward the information directly to you for review and for your specific consent. When usual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate you may review your consent for the use of disclosure of your personal information and we will explain the ramifications of that decision, and the process.


I have reviewed the above information that explains how your office will use my personal information and the steps your office is taking to protect my information. Now that your office has a privacy code, and I can ask to see the code at any time, I agree that Papini Dentistry can collect, use and disclose my personal information as said above about the offices privacy policy.

DENTAL INSURANCE POLICY

In order to make your dental visit more convenient, our office offers to bill your insurance directly. We accept different insurance providers. Please contact us for more details!

I have read and understood the above information and had the opportunity to ask questions and receive answers. I understand that responsibility for payment of the dental services for my dependents and myself is mine, and I assume responsibility for fees associated with these services. I authorize Papini Dentistry to receive payment from my insurance company directly.


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