1Medical History2Privacy3Insurance Country Park Dental 101-1450 Block Line Road, Unit #101 Kitchener, ON N2C 0A5 Patient InformationToday's Date* Day Month Year Patient Name* First Middle Last Date of Birth* Day Month Year Age*GenderWhat sex were you assigned at birth?MaleFemaleWhat is your current gender identity? Preferred Gender PronounA pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!What pronouns do you prefer that we use when referring to you? (check all that apply) She/her/hers He/him/his They/them/theirs Other Please specify Contact InformationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneExtension Number Cell PhoneEmail* 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 PrimaryInsurance Provider/Company Name Name of Insured First Last Is Insured a patient?YesNoInsured's Birth Date Day Month Year Age Patient's relationship to insuredSelfSpouseChildOtherFront and Back of the Primary Insurance Card Drop files here or Select files Accepted file types: jpg, png, gif, pdf, Max. file size: 128 MB. SecondaryName of Insured First Last Is Insured a patient?YesNoInsured's Birth Date Day Month Year Age Patient's relationship to insuredSelfSpouseChildOtherFront and Back of the Secondary Insurance Card Drop files here or Select files Accepted file types: jpg, png, gif, pdf, Max. file size: 128 MB. Do you or have you ever had an adverse reaction or allergy to* No Antibiotic Aspirin/Advil Codeine Latex Local Anesthetics/Novocain Other Please specify Which Antibiotic Do you take blood thinners (e.g Coumadin, Plavix, etc.)*YesNoSpecify the date and score of most recent INR Do you take any other medications, vitamins or supplementsYesNoName of medication What condition you take it for(List any additional meds you take on separate sheet)Other medical conditions Asthma Bleeding problems Epilepsy Prosthetic heart valve Artificial joint Hepatitis Tuberculosis HIV/AIDS Thyroid Disease Cancer Chemo/radiation Sleep apnea Steroid Use Kidney Problems Psychiatric therapy Change in health in last year Any addiction Breathing/COPD Hearth Disease Vertigo Cold Sores/fever blisters Diabetes TMJ Issues/Concerns Surgery where do you keep your inhaler? Surgery DetailsSpecify any of the above conditionsAre there any conditions or diseases not listed above that you have or have had?YesNoWhat are they?None of the aboveHave you ever had any complications following dental treatment?YesNoPlease explainAre you covered under Ontario Disability (ODSP)YesNoPlease specify your disabilityAre you pregnant or is it possible you are pregnant?*YesNoDue Date Day Month Year Are you now under the care of a physician, regarding an ongoing medical issue?*YesNoPlease explainDo you have any health problems that need further clarification?*YesNoPlease explainDo you smoke?*YesNoUsed toHow many cigarettes a day? When did you quit? Day Month Year Do you use any recreational drugs?*YesNoPlease list which kind:Do you have a prosthetic or artificial joint ?*YesNowhere ?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?*YesNoEnter 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* Day Month Year 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 ?*YesNoDo any of your teeth ache ?*YesNoDo your gums bleed when you brush ?*YesNoDo you have pain when you chew ?*YesNoDo you feel you have bad breath ?*YesNoPlease 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* Day Month Year Country Park Dental 101-1450 Block Line Road, Unit #101 Kitchener, ON N2c 0A5 HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENT’S 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 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 assess your health needs and advise you of treatment options To enable us to contact you, establish and maintain communication with you To offer and provide treatment, care and services in relationship to oral maxillofacial complex and dental care in general To communicate with other treating health care providers, including specialists and general dentists who are the referring dentists an/or peripheral dentists To allow us to maintain communication and contact with you to distribute health-care information, and to book and confirm appointments To allow us to efficiently follow-up for treatment, care and billing. To complete and submit dental claims for third party adjudication and payment To comply with legal and regulatory requirements, including the delivery of patients’ charts and records in the Royal College for Dental Surgeons of Ontario in a timely fashion, when required according to the provisions of the Regulated Health Professions Act To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons in a timely fashion for regulatory and monitoring purposes. To permit potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale To deliver charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and damages, if any To prepare material for the Health Professions Appeal and Review Board (HPARB) To invoice for goods and services and process credit card payments To collect unpaid accounts To assist that this office comply with all regulatory requirements To comply generally with the law By signing the consent of this patient consent form, you have agreed that you have given your informed consent to the collection, use and /or disclosure of 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. Our office has a Privacy Code and you can ask to see it anytime. After reviewing the above information, I agree that, Dr. Sorin Mitrana’s Dental Office, can collect, use and disclose personal information about myself, and my family, as set out in the information about office’s privacy policies. Signature* Print Name* Date* Month Day Year COUNTRY PARK DENTAL 1450 Block Line Road, Unit #101 Kitchener, ON N2C 0A5 PATIENT IS RESPONSIBLE FOR OWN DENTAL INSURANCE To Our Patients Who Have Dental Insurance, We are very pleased that you have selected us to perform your dental treatment. It is our wish that your dental health is the very best, that it can be. With the assistance that your insurance company provides, good dental health is a simple matter. Your insurance coverage is an arrangement between your insurance company and your place of employment. There are many different policies and forms of coverage, for example, some plans cover as little as 20% of dental treatment costs, while others cover as much as 100%. Please be aware that your coverage may not be based on the current dental fee guide. The amount of coverage that has been arranged does not involve the dentist. Our staff would be happy to complete your insurance forms and mail them to your insurance company. Your insurance company will in turn send the funds directly to this office. The unpaid portion that your dental plan does not cover, is your responsibility. The out of pocket portion must be paid at each appointment You are responsible for any treatment no longer covered by your dental plan. *If you do OR do not have dental insurance, please sign below acknowledging you are responsible for 100% of the payment.* Please feel free to ask if you have any questions. Patient’s Acknowledgment: I have read and understand the above, and agree to assume full liability for fees not covered by my insurance plan. Patient’s Signature* Date* Day Month Year
