New Patient Form - Country Park Dental

Country Park Dental

101-1450 Block Line Road, Unit #101 Kitchener, ON N2c 0A5

Patient Information

Today's Date*

DD

MM

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Patient Name*

First Middle Last

Gender

Family Status*

Date of Birth*

DD

MM

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Age*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Extension Number

Cell Phone

Email*

Health Card Number*

Family Physician*

First Last

Physician's Phone*

In Case of Emergency, We should notify:*

First Last

Relationship*

Phone*

Responsible Party Information Insurance Information

*Please note, patient is responsible with providing us a copy of their insurance card(s).*

Party responsible for payment*

Self
Other

Specify party responsible for payment

Primary

Insurance Provider/Company Name

Name of Insured

First Last

Is Insured a patient?

Insured's Birth Date

DD

MM

YYYY

Age

Patient's relationship to insured

Secondary

Name of Insured

First Last

Is Insured a patient?

Insured's Birth Date

DD

MM

YYYY

Age

Patient's relationship to insured

Do you or have you ever had an adverse reaction or allergy to*

Antibiotic
Aspirin/Advil
Codeine
Latex
Local Anesthetics/Novocain
Other

Please specify

Which Antibiotic

Do you take blood thinners (e.g Coumadin, Plavix, etc.)*

Specify the date and score of most recent INR

Do you take any other medications, vitamins or supplements

Name of medication

What condition you take it for

(List any additional meds you take on separate sheet)

Other medical conditions

where do you keep your inhaler?

Surgery Details

Specify any of the above conditions

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

What are they?

None of the above

Have you ever had any complications following dental treatment?

Please explain

Are you covered under Ontario Disability (ODSP)

Please specify your disability

Are you pregnant or is it possible you are pregnant?*

Due Date

DD

MM

YYYY

Are you now under the care of a physician, regarding an ongoing medical issue?*

Please explain

Do you have any health problems that need further clarification?*

Please explain

Do you smoke?*

How many cigarettes a day?

When did you quit?

DD

MM

YYYY

Do you use any recreational drugs?*

Please list which kind:

Do you have a prosthetic or artificial joint ?*

where ?

Do you have or have you ever had replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?*

Enter your name to confirm that best to your knowledge, all of the preceding answers and information provided are true and correct. If you ever have any change in your health, you will inform the doctors at the next appointment without fail.*

Signature of patient, parent or guardian (enter your name)*

Date*

DD

MM

YYYY

Whom may we thank for referring you to our practice ?

Google
Opencare
Facebook
Yellow Pages
Work
Newspaper
Walk-by /Business sign
Current patient of ours. Provide us with a name, So we can thank them.
Other

Please specify

Name

When was your last dental visit ?*

When did you last have dental x-rays ?*

How often do you floss your teeth ?*

How often do you brush your teeth ?*

Have you been seeing a dentist regularly ?*

Do any of your teeth ache ?*

Do your gums bleed when you brush ?*

Do you have pain when you chew ?*

Do you feel you have bad breath ?*

Please list anything else not mentioned above regarding your past dental history.

Consent for Services & Office Agreement

*I understand that my family’s appointments are valuable, and 2 Business days notice must be given if we are unable to attend appointments. A standard appointment time will incur a fee.

*I will be required to pay for my/my family’s treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (these are separate from Dental office fees). I understand the cost of any proposed treatment will be honored for a period of 90 days and following the 90 days a new exam and/or radiographs may be required at an additional fee if necessary.

*Outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*I consent to receiving reminder emails / text messages including marketing or promotional content through smile reminder as well as phone calls & voicemails stating my appointment times or changes necessary.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage (your insurance company). It is my responsibility to ensure that the treatment I request is covered. However, Country Park Dental will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Country Park Dental has NO knowledge of what is covered by my insurance plan. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

*Country Park Dental also understands your time is valuable we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible).

*Country Park Dental reserves the right to cancel an appointment, if they are unable to contact the patient & confirm the appointment.

*Country Park Dental will accept Visa, MasterCard, debit or cash.

*Country Park Dental will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent or guardian

Date*

DD

MM

YYYY

Country Park Dental

Patient Information

Responsible Party Information Insurance Information

Primary

Secondary

None of the above

Consent for Services & Office Agreement

Country Park Dental

HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S PERSONAL INFORMATION

COUNTRY PARK DENTAL

PATIENT IS RESPONSIBLE FOR OWN DENTAL INSURANCE

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