Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name* Last Name* Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Person responsible for account* Other parental consent required* Yes No Mother’s name* Business Tel*Father’s name* Business Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:Name* Relation* Home Phone*Cell Phone*Work Phone*Contact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Whom may we thank for referring you?* Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment* Insurance Company* Policy/Group #* Certificate/ID #* I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?* Yes No Not Sure/Maybe When was your last medical checkup?* MM slash DD slash YYYY Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Do you have any allergies?* Yes No Not Sure/Maybe --select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe Please list below with approximate dates* MM slash DD slash YYYY Do you have or have you ever had asthma?* Yes No Not Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?* Yes No Not Sure/Maybe Do you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe Please specify*Have you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe Please specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please specify*Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe If yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Are you nervous during dental treatment?* Yes No Not Sure/Maybe For women only: Are you pregnant or breastfeeding?* Yes No Not Sure/Maybe What is your expected delivery date?* MM slash DD slash YYYY Dental HistoryDo you have any specific dental concerns? Please list:*When was your last dental appointment?* MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Is there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe Do you feel uncomfortable or self-conscious about the appearance of your teeth?* Have you been disappointed with the appearance of previous dental work? How Our Office Collects, Uses and Discloses Patients’ Personal Health Information Our office understands the importance of protecting your personal health 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 personal health information about you for the following purposes: to deliver safe and efficient patient care to identify and to ensure continuous high quality service to assess 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 relationship to the oral and maxillofacialcomplex and dental care generally to communicate with other treating health care providers, including specialists and generaldentists who are the referring dentists and/or peripheral dentists to allow us to maintain communication and contact with you to distribute health careinformation and to book and confirm appointments to allow us to efficiently follow-up for treatment, care and billing for teaching and demonstrating purposes on an anonymous basis to complete and submit dental claims for third party adjudication and payment to comply with legal and regulatory requirements, including the delivery of patients’ charts andrecords to the Royal College of Dental Surgeons of Ontario in a timely fashion, whenrequired, according to the provisions of the Regulated Health Professions Act to comply with agreements/undertakings entered into voluntarily by the member with the RoyalCollege of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts andrecords to the College in a timely fashion for regulatory and monitoring purposes to permit potential purchasers, practice brokers or advisors to evaluate the dental practice to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation fora practice sale to deliver your charts and records to the dentist’s insurance carrier to enable the insurance companyto assess liability and quantify damages, if any to prepare materials for the Health Professions 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 all regulatory requirements to comply generally with the law 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 health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance. Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA. You may withdraw your consent for use or disclosure of your personal health information at any time.Patient Consent I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information. I agree that JM Dental can collect, use and disclose personal health information as set out above in the information about the office’s privacy policies.Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY To be filled out in-officeSignature of witness: Reset signature Signature locked. Reset to sign again Date: MM slash DD slash YYYY I agree to receive SMS and emails with related information and updates.
