Patient Information Name: Date of Birth: Age: Phone #: SEX : Male Female Non Bi Cell #: Address: Postal Code: Other #: Parent / Guardian: Name: Email: Employment: Marital Status: Single Married Widowed Divorced Common-Law (If Applicable) Full name of Secondary: Date of Birth: Phone #: Address: Postal Code: Patient Medical History: Alberta Health Card #: General Physician: Phone #: General Dentist: Phone #: How did you hear about us? Have you ever had a serious illness, or are you under the care of a physician? Yes No Have you had a medical examination in the last year? Yes No Have you experienced an unusual reaction to local anesthetic (freezing)? Yes No Have you ever had any of the of the following diseases? Please check Hepatitis Jaundice Heart Murmur Heart Disorder Fainting Spells Ulcers Tuberculosis Heart Attack Diabetes Cancer Epilepsy AIDS/HIV High Blood Pressure Thyroid Disease Venereal Disease GI Disease Stroke Kidney Disease Lung Disease Mental Disorder Glaucoma Rheumatic Fever Other (Please Specify): Do you have asthma, hay fever, or skin rash? Yes No Do you have a pacemaker? YesNo Have you experienced an unusual reaction to any of the following? Please Check Aspirin Codeine Penicilin Sleeping Pills Antibiotics Latex Barbiturates Sedatives Sulfonamides(Sulfa) Tranquillizers Other-Please Specify: Do you bruise easily or bleed abnormally? YesNo Do you have any blood disorders such as anemia (thin blood)? YesNo Have you ever had an injury, surgery, or x-ray therapy on your face or jaws? YesNo Is there history of family disease? FD YFD N Please Specify: When was your last dental check-up /cleaning? Do you have any oral habits such as clenching, grinding, or nail biting? YesNo What dental condition concerns you? Is there any other information regarding your health or previous dental visits that we should know? Women: Are you pregnant? YesNo *** Please Note*** As of January 1, 2004, due to new privacy law, our staff CANNOT call your dentist for your insurance information. However, YOU can contact your dentist for the information PRIMARY INSURANCE Name of Insurance Your Name (as it appears on the insurance card) Employer Cardholder's Date of Birth Group/Policy/Contract/Plan # Certificate/ID #: SECONDARY INSURANCE Name of Insurance Your Name (as it appears on the insurance card) Employer Cardholder's Date of Birth Group/Policy/Contract/Plan #: Certificate/ID #: If you are currently on SOCIAL SERVICES/AISH or have TREATY STATUS, please present your card to the front desk. Name of Insurance Your Name (as it appears on the insurance card) Employer Date of Birth Group/Policy/Contract/Plan #: Certificate/ID #: If you require a Pre-determination before treatment is completed, you must notify us prior to the beginning of treatment. It may take 2-4 weeks to receive the predetermination by mail. Please read the predetermination carefully and contact us when you receive it. I authorize release to my dental benefits plan administrator and CDA, of information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described, to the named dentist. This authorization shall continue in effect until the undersigned revokes the same. Privacy/Information Consent: Our office is committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by the law. We collect information from our patients such as name, home address, home and work telephone numbers. Contact information is collected and used for the following purposes: 1.To open and update files 2.To invoice patients for dental services, to process credit card payment, or collect on unpaid accounts through the clinic or third-party collections? 3.To process claims for payment of reimbursement from third-party health benefit providers and insurance companies. 4.To send reminders to patients concerning the need for further dental examination or treatment. Do you want to receive a Birthday Card?YesNo 5. Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or we have submitted a claim on the patient’s behalf. 5. Financial information is collected in order to make arrangements for the payment of dental services. We collect information from our parents about their health history, family health history, physical condition and dental treatments. (Collectively referred to as “Medical Information”). Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patient medical information is disclosed: 1. To third party benefit providers and insurance companies where either patient or office has submitted a claim 2. To the other dentists and dental specialists if the patient, with their consent has been referred from 3.To other health care professionals such as physicians. If we are ever to sell all or parts of our practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information. If the occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College, which may inspect records and interview staff as part of its regulatory activities in the public interest. I consent to the collection, use and disclosure of my personal information as set out above. Please prove you are human by selecting the House.