North York Dentist | North York Dental Office

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    • NEW PATIENT FORMS SECTION
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  • APPOINTMENT REQUEST

COMPLETE PATIENT MEDICAL,DENTAL,OFFICE & PRIVACY POLICIES FORM

FULL NEW PATIENT INFORMATION FORMS (4 IN 1)

MM slash DD slash YYYY
Patient is:

Patient information

Title:
Name:
Home address:
MM slash DD slash YYYY
Gender
Marital Status

PATIENT TELEPHONE & EMAIL CONTACT INFORMATION

Preferred Contact
Please provide your email address for the purpose of communication and appointment reminders.

In case of emergency:

COVID- 19 related questions:

Have you had covid-19 before ?
Have you received your 1st covid-19 vaccine?
Have you received your 2nd covid-19 vaccine?
Have you received your 3rd covid-19 booster vaccine?

CURRENT MEDICAL:

(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)
Max. file size: 64 MB.
Do you consider yourself currently in good health?
Do you know, approximately, when you had your last physical exam with your family Physician?

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?
Have you been hospitalized in the past two years?
Have you had any type of surgery in your lifetime?
When walking, do you ever have to stop because of pain in your chest or shortness of breath?
Are you on a prescription diet?
Have you ever been diagnosed as having a tumor or cancer?
Do you experience problems with healing?
Do you wish to speak privately with the doctor about any problem?
Are you a smoker of any kind? If yes, Please explain below if needed:
Do you bruise easily or bleed excessively?
Have you ever been warned about anesthetic risks?
Have you been told that you need to pre-medicate with antibiotics prior to your dental visit?
IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BOX BELOW:

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
Transdermal Nicotine Patches
High Blood Pressure Hypertension
Low Blood Pressure
Heart Failure
Congenital Heart Lesion
Articial Heart Valve
Heart Pacemaker
Heart Surgery
Heart Murmur
Mitral Valve Prolapse
Chest Pain
Angina pectoris
Shortness of Breath
Stroke
Anemia
Kidney Trouble
Ulcers
Asthma
Sinus Trouble
Frequent Cough
Lung Disease
Tuberculosis
Liver Disease
Hepatitis A (infec.)
Hepatitis B (serum)
Hepatitis C
Thyroid Disease
X-Ray/Cobalt Treatment
Cardiac Arrest/ Heart Attack
Head/Neck Injuries
Fainting or Dizziness
Artificial Joints/Hips
Diabetes or Hypoglycemia
Arthritis Rheumatism
Epilepsy or Seizures
AIDS(HIV Positive)
Venereal Disease
Herpes
Cold Sores
Blood Disorders
Circulation Problems
Hemophilia
Cancer
Chemotherapy/Radiation
Mental or nervous disorders
Been under psychiatric care?
Drug or alcohol addiction?
IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BOX BELOW:

Women only section:

Are you pregnant?
Are you taking birth control pills?
Are you nursing?
Are you taking fertility drugs?

Referrals:

How did you hear about our office?

Dental Insurance

Do you have Dental Insurance Coverage?
MM slash DD slash YYYY
Max. file size: 64 MB.

I have read, understood and completed the PATIENT INFORMATION AND MEDICAL BACKGROUND listed above.

Name
MM slash DD slash YYYY

COMPREHENSIVE PATIENT DENTAL HISTORY FORM

MM slash DD slash YYYY
Patient's name:
Last dental Hygiene visit or check up:

PAST AND PRESENT PATIENT DENTAL 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 any of your teeth becoming loose?
Are you suffering from pain now?
Does food get caught between your teeth?
Is there a history of gum disease in your family?
Have any of your teeth shifted?
Is there any swelling or pain in your gums?
Are you aware of sores/growths in your mouth?
Do you notice any bleeding from your gums when you brush your teeth or others?
Have you had a local anesthetic (freezing)?
Have you had any complications from a local anesthetic (freezing)?
Have you had any teeth extracted?
Did you ever have any complications from an extraction?
Does your mouth tend to get dry?
Do you have the burning sensation of lips or tongue?
Do you have a bad taste in your mouth or bad breath?
Are you nervous about having dental treatment?
IF AFTER READING THE ABOVE QUESTIONS IN THE SECTION ABOVE, AND THE ANSWERS ARE ALL NO, CHECK THE BELOW BOX:

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?
Do you use Dental aids such as proxy brushes, water flossers, dental picks etc.?
Are any teeth sensitive to:
Are you happy with the appearance of your teeth?

JAW PROBLEMS

Do you have any of the following below?

Pain (in jaw joints - ear, side of the face)?
Clicking/popping of jaw when opening/closing?
Difficulty in opening or closing your mouth?
Pain and/or difficulty in chewing?
Are you being followed-up by a dental specialist?
Pain when cleaning your teeth?
Have you ever had implant surgery in one or both of your jaw joints?

TREATMENTS

Please check off the following treatments you have had:

Oral surgery?
Orthodontic treatment (braces)?
Teeth ground or bite adjusted?
Periodontal treatment (gum surgery)?
Worn a bite plate or other appliance?
Dental implants?

HABITS

Do you clench or grind your teeth while asleep?
Do you breathe through your mouth while awake or asleep?
Do you bite your lips or cheeks regularly?

GENERAL CONSENT STATEMENT

I have read, understood and completed out the COMPREHENSIVE PATIENT DENTAL HISTORY FORM listed above.

MM slash DD slash YYYY
Name of the Patient

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:
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:
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 )

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
MM slash DD slash YYYY

Contact

PHONE: 416-223-2453

ADDRESS:139 Finch Ave. West Along Finch Ave. between Bathurst St. and Yonge St.

EMAIL:

info@newtonbrookdentistry.com

Location

Hours

  • Mon9:00am -5:00pm
  • Tues8:00am-6:00pm
  • Wed8:00am-7:00pm
  • Thu 9:00am-8:00pm
  • Fri   9:00am-3:00pm
  • Sat 9:00am-3:00pm
  • Sun-closed-
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