New Patient Form

Welcome! In order to render the best care possible it is necessary that we get to know you a little better. Of course all of this information is confidential. We appreciate you taking the time to fill out this form. Fields marked * are required. Questions with a "Yes/No" answer will automatically reveal a follow-up box if you select Yes.

Personal Information

First Name

Last Name

Gender

Male Female Other

Birth Date (year-month-day)

Mobile Phone

Address

ZIP / Postal Code

City

Province

Home Phone

Health Card No.

Family Doctor Name

Family Doctor Phone

Please write Reason for Visit Today (Examination or Emergency)

Referred By

Insurance Information

If you don't have dental insurance, you may leave this section blank.

Name of Insured

Policy Holder Date of Birth

Insurance Company

Employer

Policy No.

Policy ID No.

Medical History

1. Have you ever had a serious illness, operation, surgery, or been hospitalized?

Yes No

If Yes, explain

2. Are you under the care of a physician now for any problem?

Yes No

If Yes, explain

3. Are you taking any medicines, drugs, or pills presently?

Yes No

If Yes, explain

4. Do you have any allergies? Are you allergic to any medicines or drugs?

Yes No

If Yes, explain

5. Have you ever had freezing (local anesthetic) in your mouth?

Yes No

If Yes, explain

6. Do you bleed abnormally?

Yes No

If Yes, explain

7. Do you bruise easily?

Yes No

If Yes, explain

8. Have you ever fainted?

Yes No

If Yes, explain

9. Do you have shortness of breath?

Yes No

If Yes, explain

10. Do you have any chest pains?

Yes No

If Yes, explain

11. Do your ankles ever swell?

Yes No

If Yes, explain

12. Have you gained or lost excessive weight recently?

Yes No

If Yes, explain

13. Have you ever taken cortisone or steroids?

Yes No

If Yes, explain

14. Is there any history of family disease?

Yes No

If Yes, explain

15. Do you have a night guard?

Yes No

If Yes, explain

16. Do you smoke? If Yes, how many cigarettes/day?

Yes No

If Yes, explain

17. WOMEN: Are you pregnant? If Yes, in what stage of pregnancy?

Yes No

If Yes, explain

18. Is there anything else the dentist should know regarding your medical history that has not been mentioned?

Dental History

1. Have you ever had a complete dental examination with a full series of dental x-rays within the past 3 years?

2. How long ago was your last dental cleaning?

3. How long ago were your x-rays taken?

4. Have you had any extractions?

Yes No

If Yes, did you experience prolonged bleeding after?

5. Have you ever had any of the following dental treatments? (check all that apply)

If Yes, please provide approximate dates

6. Are you aware of bad breath or a bad taste in your mouth?

7. Have you ever had a bad experience at the dentist?

8. What is your present dental problem or needs?

Office Philosophy and Policy: (Please Read)

In an effort to determine a treatment plan that is best for your overall dental health, we must make a careful diagnosis. This involves a thorough examination, often utilizing the minimum number of X-rays necessary for accuracy.
We pledge to provide high quality dentistry in the most comfortable manner possible, with the best equipment, materials and up to date techniques.
The long term success of our effort will depend on the patients' willingness to maintain their teeth and prevent any future dental problems.
Your appointment time will be reserved especially for you. If you are unable to keep the appointment, we require 48 hours' notice; or a $75.00 charge may be applied. We do NOT accept cancellation through voicemail.
Our office policy is that services are paid for at the time of treatment, unless other arrangements have been made in advance. Under some circumstances, financial arrangements for payment may be made by consulting the patient care coordinator.
Insurance: All patients with dental insurance are responsible for their account. We are pleased that you have insurance to reimburse or minimize your personal expenditure and we will gladly complete any claim forms to assist you in coordinating your dental benefits. Please make certain you understand any limitations in your contract. We will gladly submit estimate forms, if necessary.
All urgent dental problems will be attended to the same day, under normal circumstances. You may call our office or answering service at any time.
A healthy dentist-patient relationship is based on mutual respect and understanding. Please feel relaxed and open to discuss with us, any aspect of your treatment or fees, at any time.

The privacy of personal information is an important part of providing you with quality dental care. We are committed to collecting, using and disclosing your personal information responsibly, and being as open and transparent as possible about the way we handle your personal information.

Our office is committed to:

Only collect necessary information about you.
We only share your information with your consent.
The storage, retention and destruction of your personal information complies 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.

In this office, Dr. Kayvan Ghane acts as the Privacy Information Officer. Do not hesitate to discuss our policies with Dr. Kayvan Ghane or any member of our staff. Please be assured that your privacy is respected while you receive the best quality dental care.

How our Office Collects, Uses and Discloses Patient's Personal Information

Your privacy is important to us. To help you understand how we are protecting your information, we have outlined below how our office is using and disclosing your information.

The 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 of service.
To assess your health needs and to provide health care.
To advise you of your treatment options.
To enable us to contact you and to establish and maintain communication with you.
To offer and provide treatment, care and services in relationship to the oral and dental care referring dentists and/or peripheral dentists.
To allow us to maintain contact with you to distribute healthcare information and to book/confirm appointments. This may include sending postcard-type reminders through the mail.
To allow us to efficiently follow up for treatment, care and billing.
To complete/submit predetermination and claims to your insurer, and to provide further information that your insurer may request to aid in the processing of claims.
To comply with legal and regulatory requirements, including providing records to The Royal College of Dental Surgeons of Ontario in a timely fashion when required, and in accordance with the Regulated Health Professions Act.
To invoice for goods and services, and to process payments.
To assist this office to comply with all regulatory requirements, and to comply with the law.

By signing this consent form, you agree and consent to the collection, use and/or disclosure of your personal information for the purposes that are listed above. If any new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Our office will not under any conditions supply your insurer with your confidential medical history without your specific consent. You may withdraw your consent for use or disclosure of your personal information at any time, and we will explain the ramifications of that decision.

Local Anesthesia: May cause reactions such as bruising, hematoma, temporary, or rarely permanent, numbness of the tongue, lips, teeth, jaw and/or facial tissue.

Please verify your provided information

I have reviewed the above information that explains how the office will use my personal information, and the steps that 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 Brantford Dental Care can collect, use and disclose my personal information as set out in the privacy policy I give consent to Brantford Dental Care for my Insurance Company to be contacted to help me get optimum coverage details and treatment predetermination responses

Consent for Treatment

This is to certify that I consent to the performance of examination and treatment as recommended by my dentist, and I will assume responsibility for all fees associated with all procedures.

I agree to the privacy policy and consent to examination and treatment as described above.

Date

Signature (type your full legal name)

Personal Information

Insurance Information

Medical History

Dental History

Office Philosophy and Policy: (Please Read)

Consent Form: Collection, Use and Disclosure of Personal Information (PIPEDA)

Consent for Treatment