FULL NEW PATIENT INFORMATION FORMS (4 IN 1) Date: MM slash DD slash YYYY Patient is: Adult Child Patient informationTitle: Mrs. Ms. Mr. Dr. Name: First Middle Last Patient’s preferred name: Home address: 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 Date of birth: MM slash DD slash YYYY Age:Gender Male Female Other Marital Status Single Married Common-Law PATIENT TELEPHONE & EMAIL CONTACT INFORMATIONCellular phone:Home phone:Preferred Contact Cellular phone Home phone Email Please provide your email address for the purpose of communication and appointment reminders. In case of emergency: Please notify (individual): Relationship to the patient: Emergency contact cellular phone:Emergency contact alternate phone number: COVID- 19 related questions: Have you had covid-19 before ? Yes No If yes, when? Have you received your 1st covid-19 vaccine? Yes No If so, when did you receive the vaccine? Brand type? Have you received your 2nd covid-19 vaccine( if applicable)? Yes No When? Brand type? CURRENT MEDICAL:Name of Family Physician: Phone number of Physician:Are you taking any Medications?(Please list all current medications you are taking including vitamins or supplements. Make sure to include the exact medication name, dosage, and what it is taken for)Please provide a pharmacy medications list or a written list by attaching below if you have one:Max. file size: 64 MB.Medical conditions:Allergies:Do you consider yourself currently in good health? Yes No Do you know, approximately, when you had your last physical exam with your family Physician? Yes No Please list how many years or months ago, if the answer is yes: MEDICAL HISTORY:Please check YES or NO. If not sure, check NS. To unclick a single box, click the box again and it will unclick. IF AFTER READING THE MEDICAL QUESTIONS IN THE SECTION BELOW AND THE ANSWER IS NO TO ALL QUESTIONS, SKIP TO THE END OF THE SECTION AND CHECK "NO TO ALL."Are you currently under a specialist's care or have you been under a specialist's care in the past 2 years? Yes No Please provide details below if the above answer is yes: Have you been hospitalized in the past two years? Yes No If the answer is yes to the above question, please provide details: Have you had any type of surgery in your lifetime? Yes No Please list details if the answer is yes: When walking, do you ever have to stop because of pain in your chest or shortness of breath? Yes No Are you on a prescription diet? Yes No Have you ever been diagnosed as having a tumor or cancer? Yes No Please elaborate with details and dates if the answer above is yes: Do you experience problems with healing? Yes No Do you wish to speak privately with the doctor about any problem? Yes No If the answer is yes, please explain below if desired: Are you a smoker of any kind? If yes, Please explain below if needed: Yes No Frequency, amount per day, or any details? Do you bruise easily or bleed excessively? Yes No Have you ever been warned about anesthetic risks? Yes No Have you been told that you need to pre-medicate with antibiotics prior to your dental visit? Yes No If the answer is yes, what have you been prescribed, and what condition do you have that would need pre-medication? IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BOX BELOW: NO TO ALL FOR THE ABOVE SECTION QUESTIONS ONLY Have you ever experienced or currently have the following?IF AFTER READING THE MEDICAL QUESTIONS IN THE SECTION BELOW AND THE ANSWER IS NO TO ALL QUESTIONS, SKIP TO THE END OF THE SECTION AND CHECK "NO TO ALL."Stomach Intestinal Problems YES NO Transdermal Nicotine Patches YES NO High Blood Pressure Hypertension YES NO Low Blood Pressure YES NO Heart Failure YES NO Congenital Heart Lesion YES NO Articial Heart Valve YES NO Heart Pacemaker YES NO Heart Surgery YES NO Heart Murmur YES NO Mitral Valve Prolapse YES NO Chest Pain YES NO Angina pectoris YES NO Shortness of Breath YES NO Stroke YES NO Anemia YES NO Kidney Trouble YES NO Ulcers YES NO Asthma YES NO Sinus Trouble YES NO Frequent Cough YES NO Lung Disease YES NO Tuberculosis YES NO Liver Disease YES NO Hepatitis A (infec.) YES NO Hepatitis B (serum) YES NO Hepatitis C YES NO Thyroid Disease YES NO X-Ray/Cobalt Treatment YES NO Cardiac Arrest/ Heart Attack YES NO Head/Neck Injuries YES NO Fainting or Dizziness YES NO Artificial Joints/Hips YES NO Diabetes or Hypoglycemia YES NO Arthritis Rheumatism YES NO Epilepsy or Seizures YES NO AIDS(HIV Positive) YES NO Venereal Disease YES NO Herpes YES NO Cold Sores YES NO Blood Disorders YES NO Circulation Problems YES NO Hemophilia YES NO Cancer YES NO Chemotherapy/Radiation YES NO Mental or nervous disorders YES NO Been under psychiatric care? YES NO Drug or alcohol addiction? YES NO If you answered yes to any of the above questions in this section, please elaborate below: IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BOX BELOW: NO TO ALL FOR THE ABOVE SECTION QUESTIONS ONLY Women only section: Are you pregnant? YES NO Are you taking birth control pills? YES NO Are you nursing? YES NO Are you taking fertility drugs? YES NO Is there anything further you would like to note regarding your health that we should be aware of? Referrals: How did you hear about our office? Social media Google My Physician A staff member of the office I Live In the neighborhood If you heard about our office through another source not mentioned above, please list details below:Dental InsuranceDo you have Dental Insurance Coverage? YES NO If the answer is yes, please list the name of the Insurance Company, if known: Policy holder’s full name: Policy Holder’s Date of Birth: MM slash DD slash YYYY Policy(Group or plan contract) number(if not sure please attach a picture as instructed below) : Certificate (Identification) number (if not sure please attach a picture as instructed below): If you have a picture of the insurance card or a screenshot of the insurance information, please attach here:Max. file size: 64 MB. I have read, understood and completed the PATIENT INFORMATION AND MEDICAL BACKGROUND listed above. Name Full Name Date MM slash DD slash YYYY COMPREHENSIVE PATIENT DENTAL HISTORY FORM Date MM slash DD slash YYYY Patient's name: First Last Last dental Hygiene visit or check up:When was your last dental check-up/ hygiene visit? (If you cannot recall the exact date or year, please approximate in months or years). Name of previous dentist or dental office if known: PAST AND PRESENT PATIENT DENTAL HISTORYPlease check YES or NO. If not sure, check NS To unclick a single box, click the box again and it will unclick. IF AFTER READING THE MEDICAL QUESTIONS IN THE SECTION BELOW AND THE ANSWER IS NO TO ALL QUESTIONS, SKIP TO THE END OF THE SECTION AND CHECK "NO TO ALL."Are any of your teeth becoming loose? Yes No Are you suffering from pain now? Yes No Does food get caught between your teeth? Yes No Is there a history of gum disease in your family? Yes No Have any of your teeth shifted? Yes No Is there any swelling or pain in your gums? Yes No Are you aware of sores/growths in your mouth? Yes No Do you notice any bleeding from your gums when you brush your teeth or others? Yes No Have you had a local anesthetic (freezing)? Yes No Have you had any complications from a local anesthetic (freezing)? Yes No Have you had any teeth extracted? Yes No Did you ever have any complications from an extraction? Yes No Does your mouth tend to get dry? Yes No Do you have the burning sensation of lips or tongue? Yes No Do you have a bad taste in your mouth or bad breath? Yes No Are you nervous about having dental treatment? Yes No IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BELOW BOX: NO TO ALL FOR THE ABOVE SECTION QUESTIONS ONLY ORAL HYGIENE Please check YES or NO. if not sure, please check NS. To unclick a single box, click the box again and it will unclick. Do you use any fluoride/mouth rinses? Yes No Do you use Dental aids such as proxy brushes, water flossers, dental picks etc.? Yes No Are any teeth sensitive to: sweet hot cold pressure biting Are you happy with the appearance of your teeth? Yes No What would you like to change about your teeth? How often do you brush your teeth? How often do you floss your teeth? JAW PROBLEMS Do you have any of the following below? Pain (in jaw joints - ear, side of the face)? Yes No Clicking/popping of jaw when opening/closing? Yes No Difficulty in opening or closing your mouth? Yes No Pain and/or difficulty in chewing? Yes No Are you being followed-up by a dental specialist? Yes No Pain when cleaning your teeth? Yes No Have you ever had implant surgery in one or both of your jaw joints? Yes No If yes, who performed the surgery and when was it done? TREATMENTS Please check off the following treatments you have had: Oral surgery? Yes No Orthodontic treatment (braces)? Yes No Teeth ground or bite adjusted? Yes No Periodontal treatment (gum surgery)? Yes No Wom a bite plate or other appliance? Yes No Dental implants? Yes No HABITS Do you clench or grind your teeth while asleep? Yes No NS Do you breathe through your mouth while awake or asleep? Yes No NS Do you bite your lips or cheeks regularly? Yes No Is there anything else you would like us to know? GENERAL CONSENT STATEMENT I have read, understood and completed out the COMPREHENSIVE PATIENT DENTAL HISTORY FORM listed above. Date MM slash DD slash YYYY Name of the Patient First Last Our Office Policies Cancellation: The appointments are reserved time for you only. A minimum notice of two business days is required to avoid possible cancellation fees. Payment: Full payment is required at the time of each appointment. We accept cash, debit, VISA and MasterCard. HST is not charged. If you have any insurance benefits, they will only be assigned to you. You will pay us in full and we will send your insurance on your behalf electronically or manually in some cases. Insurances: Co-payment is required at the time of each appointment as well as any deductibles or fee guide differences that may arise. As everyone’s insurance details are unique it is not possible for us to be accountable for knowing all of the details pertaining to your specific plans coverage. As a courtesy, we will be more than happy to assist you with the processing of your dental claims, either electronically or manually on your behalf. We will not waive any insurance fees under any circumstances. Privacy: According to the Privacy Policy Act (PIPEDA), Dr. Safari & Associates is to withhold all patient information and acknowledge it as strictly confidential. Patient authorizations/signatures are required prior to the release of any information to a third party other than a collection agency. I have read and understood the OFFICE POLICIES listed above. Patient Name: Full Name Date MM slash DD slash YYYY PATIENT PRIVACY CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. In this office, Dr. Mark Safari, 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 that you have 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: All the necessary information is collected about you; We only share information with your consent; Storage, retention and destruction of your personal information compiles with existing legislation, and privacy protection protocols; Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Do not hesitate to discuss our policies with me or any other member of our office staff. Please be assured that every staff member in our office is committed to ensuring that you receive the best quality dental care. I have read and understood the PATIENT PRIVACY CONSENT FORM listed above. Patient full name: Full Name I agree that I have read all of the consent forms above which include the following 4 forms: (please check next to each form that was read and understood ) Complete patient information intake and medical history form Complete patient past and current dental history form Our office policies Patient privacy consent form General Consent statement and attestation I certify that I have read, understood, and accurately completed the personal, medical, dental histories, as well as our office policies and privacy statement to the best of my knowledge, and have not knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding any medical and dental histories.I attest that the above medical information is true and completed to the best of my ability. I understand that by disclosing all of my medical information to my dentist or dental hygienist, that it is in my best interest to do so medically. As may be required, I consent to my physician being contacted regarding any specific medical question. I authorize the dentist to perform necessary diagnostic procedures and treatment, including general or local anesthetic, as required, to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive. I know that your office has a privacy code, and I can ask to see the code at any time. I agree that your office can collect, use and disclose personal information about me as set out in your office privacy policy. Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office. Patient Name First Last SignatureDate MM slash DD slash YYYY
