New Patient Information

In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

PATIENT INFORMATION

Your Name:*

Date of Birth:*

Your Address:*

CONTACT INFORMATION
Emergency Contact:
Phone Number:
Family Doctor:
Phone Number:
REFERRAL SOURCE
How did you hear about us?
FINANCIAL INFORMATION
Do you have Dental Insurance?* Yes   |   No

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

Insurance Company

Insurance Year End:

% Coverage For:

Name of Insured (if different from above):

Date of Birth:*

Insured Address:*

DENTAL HISTORY

What is the reason for today's visit?  Emergency  Examination  Other:

How frequently do you see your dentist?  3-6 months  Annually  Other:

Date of your last dental visit?  

Date of your last dental X-Ray?  

How often do you brush per day? Floss? Use anti-bacterial rinse?

Are your teeth sensitive to: Cold Sweets Heat Other

Do your gums bleed when: Brushing Flossing Never

Do your gums feel swollen or tender?
Do your have bad breath or bad taste in your mouth?
Do your jaws crack, pop, or grate when you open widely?
Do you grind or clench your teeth?
Do you have food catch between your teeth?
Have you ever had local anaesthetic (freezing)? If yes did you have any problems?
Have you ever had any problems with previous dental treatments? If yes, please specify?

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

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

Are you satisfied with your teeth? Specify:

MEDICAL HISTORY

Are you presently being treated by a physician?*

If yes, please explain why:

Have you ever been hospitalized?

If yes, please explain why:

Are you currently taking any medications, pills, or drugs?*

If yes, please list:

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

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)

Have you ever been warned against using any other medications?

If yes, please list:

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

If yes, please list:

Do you bruise easily or have prolonged bleeding?

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

Do you smoke?

If yes, how much per day?

Are you pregnant?

Are you using birth control?

Have you reached menopause?

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
Leukemua
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

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Is there anything else we should know about your health?

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. Eitan Keren 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 enerally
  • 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 Eitan Keren Dentistry Professional Corporation 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. However:

  • Keep in mind that the doctor does not have a contract with the insurance companies, YOU DO!
  • Any deductible and /or co-payment are due upon treatment.
  • Although we try our best to keep within your insurance coverage, this may not always be possible. Insurance companies do not give us every little detail on dental policies, therefore we cannot guarantee that all treatment rendered will be fully covered.
  • Please note that some insurance companies have a non-assignment policy, which means that they DO NOT send cheques directly to the dentist. Patients with such policies are required to pay at the time of their appointment.
  • Our office does not give a discount for any amount that is not covered by your insurance. For example, if you are covered at 80%, we cannot write off the 20%. This is your balance and you are required to pay this at the time of your appointment. It is considered insurance fraud if we write off the difference.
  • If you want us to receive payment from a third party (Your Insurance Company) we will accept the assignment of fees, but we need authorization from you to allow us to receive payment from your insurance company. We also require authorization from you to allow us to supply the insurance company with any information they may require pertaining to any claims we submit on your behalf. This may include forms such as progress notes, charting, radiographs, etc.
  • Please inform us immediately of any changes to your insurance policy, your home address and phone numbers.


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 Dufferin Vaughan Dental Centre to receive payment from my insurance company directly.