If you are a new patient please complete the following form. You may also download a pdf version of the form. Step 1 of 5 20% Personal Information First Name* Last Name* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone Work Phone Cell Phone Email* Date of Birth Insurance Information (if applicable) Insurance Coverage I do not currently have medical insurance coverage Name of Policy Holder Date of Birth Insurance Company Employer Group / Policy # Certificate / ID # Medical History Are you presently under the care of a physician?* Yes No Reason for being under care of a physician? When was your last medical checkup?* Has there been any change in your health in the past year?* Yes No Please explain changes in health* Are you taking any medications, non-prescription drugs or herbal supplements of any kind? Yes No Please list name and dosage Do you have any allergies? Yes No Please list allergies Have you ever had a peculiar or adverse reaction to any medications or injections?* Yes No Please explain any adverse reactions* Indicate which of the following you presently have, or have ever had: Angina Arthritis / Rheumatism Artifical Joints Asthma Bleeding Disorder Cancer Cardiovascular Problems Diabetes Drug / Alcohol Dependency Epilepsy Headaches Head / Neck Injury Heart Problems / Attack Heart Murmur Hepatitis High / Low Blood Pressure HIV / Aids Kidney Disease Liver Disease Lung Disease Mental / Nervous Disorders Smoke / Chew Tobacco Stroke Thyroid Disease Tuberculosis Do you have or have you had any disease, condition or problem not listed? Yes No Please list Are you nervous during dental treatment? Yes No For women, are you: Pregnant? Nursing? Using birth control? Patient Consent* I understand this information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the doctor of any change in my health or medication. Getting to Know You Our practice places a strong emphasis on getting to know you and using that information to assist us in developing your personalized dental plan. Please answer the following questions. What specific concerns would you like addressed? How do you feel about the present health of your mouth? How did you hear about our office? Do you need treatment completed by a certain date? Are there any obstacles you forsee in receiving dental care? Is there anything about the appearance of your teeth that you would change? What caused you to leave your last dentist? Is there any additional information you would like us to know (past dental experiences good or bad, specific fears, etc.)? Patient Consent Privacy Policy* I have reviewed the Privacy Policy and the description on how my information is protected by the Privacy Policy and the steps the office is taking to protect my information. I understand that your office has a Privacy Code, and I can ask to see the Code at any time. Financial Policy* I have read and understood the financial policy and am aware of my responsibility for payment the day services are provided. Insurance Information* I have read and understood the important information regarding insurance benefits Patient Consent Form - Collection, Use and Disclosure of Personal Information We understand the importance of protecting your personal information. All team members who come into contact with your records are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate use and proper protection of your information. In this office Dr. Sukhman acts as the privacy Officer. Outlines of what the consent entails and what our office is doing to ensure your privacy are as follows: 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 existing legislation and privacy protection protocols as outlined by the Royal College of Dental surgeons of Ontario Do not hesitate to discuss our policies with Dr. Sukhman or any member of our team. How Our Office Collects, Uses and Discloses Patient’s Personal 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 provide care to offer, advise and provide treatment options, care and services in relationship to the oral and maxillofacial complex and dental care to establish and maintain communication with you, including booking and confirming appointments to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists to allow us to efficiently follow-up for treatment, care and billing for teaching and demonstrating on an anonymous basis 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 to the Royal College of 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 of Ontario, including the delivery and/or review of patient’s charts and records to the College in a timely fashion for regulatory and monitoring purposes to permit potential purchasers, practice brokers or advisors to evaluate the dental practice and/or conduct an audit in preparation for a practice sale to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any to prepare materials for the Health Professionals Appeal and Review Board to process credit card payments and collect unpaid accounts to assist this office to comply generally with the law and all necessary regulatory requirements. By agreeing to the consent section 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 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. Your information may be accessed by the regulatory authorities under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event that this request is made, we will forward the information directly to you for review, and for your specific consent. Financial Policy Payment is expected in full at the time of service. We offer a number of payment options for your convenience: Credit Card – Visa, MasterCard, AMEX Cash or Debit Personal Cheque ($50 NSF Fee) DentalCard (On approved credit) For those patients with insurance, your benefits are based on a contract negotiated between your employer and the insurance company and are not intended to cover all dental treatment. While we will make every effort to maximize your benefits, we do not accept insurance cheques as payment. On your behalf, we will file your claim and the insurance payment will come to you directly, usually in less than one week. Insurance companies will often only provide coverage for the cheapest possible treatment alternatives which are not necessarily in our patients’ best interest. While you will always have the choice of what level of care you receive within our office, we will suggest what we think is the best treatment for you and your family based on our clinical findings, not based on what we expect an insurance company to cover. Cancellation Policy Your appointment is a time reserved especially for you. It is your responsibility to record this reserved time for future reference. As a courtesy, we will remind you of appointments by phone as the date approaches. We require 48 hours notice, during business hours, to change or cancel an appointment. Late notice or missed appointments may be subject to a minimum $50 charge. Important Information Regarding Insurance Benefits It is vitally important that our patients understand the role that insurance has in their oral health. First, insurance should only be considered a benefit to assist in the cost of dental care and not universal coverage. It is simply a contract between the insurance company and the employer that determines what benefit can be paid towards dental treatment. There are literally thousands of different plans, and while we can often inquire on your behalf, it is ultimately your responsibility to know the terms of the contract – your benefits coordinator would be the ideal person to contact if you are unsure of the details. We want to make it very clear that insurance companies are in business for profit. They say and do many things to interfere with the relationship between the patient and the dentist. They do not look out for our patient’s best interest, and they often attempt to interfere with our ability to provide high quality dental treatment. One very common example is, “The patient is eligible for 9 month recall.” In this case the insurance company makes it seem like you are only eligible for cleanings every nine months. In almost all cases, this nine month interval only applies to the check up with the dentist. There are usually provisions that will pay for additional cleaning visits in between check ups, as nine months is too long a period for almost all adults to maintain their periodontal/gum health. There are limitations in all benefit plans for what the employer will cover from annual maximums, to limited coverage on ‘major’ procedures, to providing coverage for only the least expensive alternative for treatment. Again, when a patient receives notices from the insurance company, it is often confusing, and the patient can be led to believe that if a procedure is not covered, then it might be unnecessary. Nothing could be further from the truth, and by rejecting proposed dental treatment, it lines the pockets of the insurance company, and provides obstacles to you receiving the quality of care that you deserve. In our practice, the patient is always in control of deciding which treatment they wish to receive. If you wish to have only dental care that is covered by your plan, it is your responsibility to make this very clear to us, and we will do our best to stay within the confines of your benefits. However, it is our responsibility to let you know that in many cases, by limiting the level and amount of care that you are receiving, that the outcome of treatment often becomes less predictable.
