1 Patient Information2 Health Information3 Consent for Services & Office Agreement Patient InformationToday's Date* MM DD YYYY Name First Middle Last GenderMaleFemaleDate of Birth MM DD YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneWork PhoneExtension NumberCell PhoneHealth Card NumberEmail Family Physician First Last Physician's PhonePhysician's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Preferred appointment times Morning Afternoon Evening Any Time Preferred appointment day Monday Tuesday Wednesday Thursday Friday Any Day Are you interested in improving your smile?YesNoAre you interested in whitening your teeth?YesNoAre you interested in replacing any missing teeth?YesNoDo you have any old fillings or dental treatments that you are unhappy with?YesNoDo your gums bleed while brushing or flossing?YesNoAre you having any trouble with your teeth or gums?YesNoHave you ever had a difficult extraction in the past?YesNoHave you ever had any prolonged bleeding or problems healing following an extraction / dental treatment?YesNoEmployment InformationEmployer NameOccupationEmployment PhoneResponsible Party Information Insurance InformationParty responsible for payment Self Other Specify party responsible for paymentPrimaryName of Insured First Last Is Insured a patient?YesNoInsured's Birth Date MM DD YYYY ID NumberGroup NumberPatient's relationship to insured:SelfSpouseChildOtherSpecifySecondaryName of Insured First Last Is Insured a patient?YesNoInsured's Birth Date MM DD YYYY ID NumberGroup NumberPatient's relationship to insured:SelfSpouseChildOtherSpecifyReferral InformationWhom may we thank for referring you to our practice? Another dental office Google Facebook Yellow Pages Work Newspaper Walked by location Other Please specify Health InformationDate of last dentl visit MM DD YYYY Reason for today's visitDo you or have you ever had an adverse reaction or allergy to: Antibiotic Aspirin/Advil Codeine Latex Local Anesthetics/Novocain Other Please specifyWhich AntibioticDo you take blood thinners (e.g Coumadin, Plavix, etc.)YesNoSpecify the date and score of most recent INRDo you take any other medications, vitamins or supplementsYesNoSpecify name of medication and what condition you take it forWhat is your level of anxiety/stress/fear when going to the dentist?NoneMildModerateSevereOther 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 Surgery DetailsSpecify the conditonHave you ever had any complications following dental treatment?YesNoPlease explainHave you been admitted to a hospital or needed emergency care during the past two years?YesNoAre you pregnant or is it possible you are pregnant?YesNoDue Date MM DD YYYY Are you now under the care of a physician?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? MM DD YYYY Do you use any recreational drugs?YesNoPlease list which kind:Do you take antibiotics prior to dental work or surgery?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.* 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 of 30 minutes will incur a fee of $50.00. *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 will always make every attempt to see emergency cases promptly. *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 (enter your name)*Date* MM DD YYYY
