Patients Form

Personal Information:

Preferred Title:(Required)
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Address(Required)
Preferred Contact Method?(Required)

In case of emergency please notify:

Dental Insurance Information:

Primary Dental Insurance:

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Address (If Different From Above)

Secondary Dental Insurance:

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Address (If Different From Above)

Financial Policies:

Our practice helps patients to collect their insurance benefits by completing the standard dental form. In all cases, the patient is fully responsible for the complete cost of treatment on the day of their appointment. We accept Visa, American Express, MasterCard, cash and debit card. A 50% deposit is required for all extensive treatment. The balance of the fee is to be paid following the completion of the extensive treatment plans we are happy to set up written payment plans. Emergency patients who are not regular patients of our office, and who have not established a credit rating with us, are expected to pay for services rendered. In the event that an emergency occurs after regular business hours, the fees incurred will include a full emergency exam fee, plus a fee for any treatment performed. We require 2 business days notice to change or cancel all appointments. Failure to do so may result in a $100 service fee. A service charge of $50 will be applied to any returned cheques. Any accounts sent to collections will be charged an administrative fee of $100.

Financial Policy Confirmation(Required)
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Health Information:

The following information is required by our clinical dental team to assist in proper diagnosis and treatment planning. All information is strictly confidential. Please check YES or NO to each question. If you are unsure of a question, please contact your dental provider.

1. Do you identify as a patient with a disability?(Required)
2. Are you being treated for any medical condition at present or within the past 2 years?(Required)
3. Have you been hospitalized or had a serious illness in the last 2 years?(Required)
4. Has there been any changes in your general health in the past year?(Required)
5. When was your last medical check up?(Required)
6. Have you recently or are you presently taking any PRESCRIPTION or NON PRESCRIPTION drugs?(Required)
7. Have you ever reacted adversely to any of the following? PLEASE CIRCLE Antibiotics (e.g. Penicillin), Aspirin, Local Anaesthetic ("dental freezing"), Codeine, Nitrous Oxide ("laughing gas"), or other:(Required)
8. Do you have any of the following? PLEASE CIRCLE: Asthma, Hay Fever, Food Allergies, Metal or latex Allergies, Skin rashes, hives, or any other allergic condition?(Required)
9. Do any of these allergic conditions result in head ache, nausea, swelling, shortness of breath or chest constriction? If yes, please explain:(Required)
10. Have you had any injury to or surgery on your face or jaws? If yes, please explain:(Required)
11. Do you smoke, or use any other form of tobacco/cannabis/vape?(Required)
12. Are you presently using nicotine replacement therapy (patch, gum)?(Required)
13. Are you alcohol, cannabis or drug dependent?(Required)
14. Women only: Are you pregnant or is there a chance you may be?
If yes, are you breastfeeding?

Indicate which of the following you have experienced:

Chest Pain
Swollen ankles, feet or hands
Shortness of breath
Recent weight loss, fever, night sweats
Persistent cough, coughing up blood
Bleeding problems, bruising easily
Sinus Problems
Dizziness
Ringing in the ears
Hearing difficulty
Ear aches
Severe headaches
Fainting spells
Blurred vision
Seizures
Excessive thirst
Dry mouth
Difficulty swallowing
Frequent vomiting, nausea
Joint pain/stiffness
Throat infections

Dental Information

Select only those that apply to you
Are there any conditions or diseases not listed above that you have or have had?

Indicate which of the following you have or ever had:

1. Are you having any dental problems or discomfort with your mouth that needs immediate attention?
3. Have you been seeing a dentist regularly?
4. Have you ever had a bad dental experience or complication?
5. Do you experience anxiety or nervousness during dental appointments?
7. Do you need antibiotics before dental treatment?
8. Do you have or have you had any of the following? Please check those that apply:
9. Are there any growths or sore spots in your mouth?
10. Do your gums bleed when brushing/flossing or do you suffer pain or swelling of your gums?
11. Have you noticed any of your teeth are loose or shifting?
12. Have you lost any teeth or have you had any extractions?
13. Does food get caught between your teeth?
14. Are any of your teeth sensitive to hot, cold, sweets or pressure?
16. Do you use any of the following? Please check those that apply:
17. Do you have or have you had an unpleasant taste or odour in your mouth?
18. Do you experience or have you experienced any of the following? Please check those that apply:
19. Do you have any of the following habits? Please check those that apply:
20. Are you happy with the appearance of your smile?

General Release

I, the undersigned, certify that all the personal, dental and medical information provided in this document is true to the best of my knowledge, and I have not omitted any information. I have had the opportunity to ask questions and receive answers to my questions regarding my dental and medical history. Should there be any change in my health status in the future, I will advise the office. I authorize the clinical team to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information.

I am a:(Required)
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Patient consent form: For collection, use and disclosure of personal information

By signing 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 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.

For the full patient consent form policy, please see: Patient Consent

Patient Consent

I have reviewed the above information that explains how the office will use my personal information, and the steps the office is taking to protect my information. I know that the office has a Privacy Code, and I can ask to see the Code at any time. I agree that Dentistry in Dufferin and Simcoe (DDS) can collect, use and disclose personal information about me as set out above in the information about the office's privacy policies.(Required)
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