Papini Dentistry Patient Form | Woodbridge, ON

PATIENT INFORMATION

Title:

Patient Name:

First

Last

Date of Birth

Sex

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Employer

Occupation

CONTACT INFORMATION

Emergency Contact:

Phone Number

Family Doctor:

Phone Number

REFERRAL SOURCE

How did you hear about us?

INSURANCE INFORMATION

Do you have Dental Insurance?

Yes
No

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

Primary Insurance Information

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

Annual Coverage

% Coverage For:

Secondary Insurance Information (if applicable)

Name of Insured:

Patient's Relationship to Insured:

Date of Birth:

Insurance Provider

Insurance Year End:

Annual Coverage

% Coverage For:

MEDICAL HISTORY - All information is Confidential

Are you presently being treated for any medical condition at the present or within the past year?

Yes
No

If yes, please explain why:

Was your last medical checkup within the past year?

Yes
No

Has there been any change in your general health in the past year?

Yes
No

Are you currently taking any medications or non-prescription drugs of any kind?

Yes
No

If yes, please list:

Have you ever been warned against using any other medications?

Yes
No

If yes, please list:

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

Yes
No

If yes, please list:

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

Yes
No

If yes, please list:

Do you or did you smoke?

Yes
No

If yes, for how long?

Do you drink alcoholic beverages on a regular basis?

Yes
No

Do you use recreational drugs? (e.g. cocain or amphetamines)

Yes
No

(For women only) Are you pregnant?

Yes
No

If yes, when is your due date?

Do you bruise easily or have prolonged bleeding?

Yes
No

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

Yes
No

Are you anxious during dental treatments? (Please indicate by marking the scale)

If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?

Yes
No

Have you ever had any serious trouble with any previous dental treatment?

Yes
No

If yes, please describe:

Is there anything else we should know about your health?

DENTAL HISTORY - All information is Confidential

Previous Dentist:

Why did you leave your last dentist?

How often do you have you teeth cleaned?

3-6 months
Annually

Other:

What is your IMMEDIATE dental concern?

Date of your last dental visit?

Date of your last dental X-Ray?

Please select YES or NO to the following:

1. Are you satisfied with the appearance of your teeth?

Yes
No

If no, please specify:

2. Did you have any unfavourable dental experiences?

Yes
No

3. Do you have dental fears?

Yes
No

12. Have of

4. Are you nervous about your dental treatment?

Yes
No

5. Problems with effectiveness or bad reactions to dental anesthetic?

Yes
No

6. Bleeding gums?

Yes
No

7. Avoid brushing any part of your mouth?

Yes
No

8. Sensitive to temperature? (hot or cold)

Yes
No

9. Does food get caught between your teeth?

Yes
No

10. Sore teeth?

Yes
No

11. Burning sensation in your mouth?

Yes
No

12. Difficulty swallowing?

Yes
No

13. An unpleasant taste or odour in your mouth?

Yes
No

14. Dry mouth?

Yes
No

15. Jaw problems (temporomandibular joint or TMJ)?

Yes
No

16. Stiff neck muscles?

Yes
No

17. Tension headaches?

Yes
No

18. Clench or grind your teeth?

Yes
No

19. Lost any teeth?

Yes
No

Do you have or have you had any of the following procedures? Please check all that apply:

Please elaborate if you have any of the above:

Supplemental Denture History:

If you are wearing a partial or complete artificial denture, please complete the following:

Has your present denture been relined? When?

Is your present denture a problem? Describe:

Are you satisfied with your appearance?

Are you satisfied with your chewing ability?

When did you receive your first partial or complete denture?

How long have you worn your present denture?

CONSENT

I acknowledge that the information given to me is true to the best of my knowledge and that the questions have been reviewed with me. Should there be any changes to my present health status in the future, I will advise Papini Dentistry. I have been informed that my physician may be contacted by letter, email, fax, or telephone in order to complete details of my medical history. I hereby consent to my physician providing Papini Dentistry with any information in this regard which may ensure safe dental treatment. Finally, I hereby acknowledge that dental treatment may be delayed until all medical information required by Papini Dentistry is received.

Patient Name

Date

Patient Initials

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. Papini 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 generally
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 Papini Dentistry 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. We accept different insurance providers. Please contact us for more details!

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 Papini Dentistry to receive payment from my insurance company directly.

Patient Information

PATIENT INFORMATION

CONTACT INFORMATION

REFERRAL SOURCE

INSURANCE INFORMATION

MEDICAL HISTORY - All information is Confidential

DENTAL HISTORY - All information is Confidential

Please select YES or NO to the following:

Supplemental Denture History:

CONSENT

GENERAL RELEASE

PRIVACY CONSENT

DENTAL INSURANCE POLICY