Cedar Dental

Patient Information

A parent or guardian will be responsible for decisions on my treatment

Yes No

Medical Alert

First Name

Initial Name

Last Name

Date Of Birth

Street

Apt.

City

Prov.

Postal Code

Home Tel

Work Tel

Cell

Referred By

Emergency Contact

Tel

Family Doctor

Tel

Financial Information

Method of Payment

Cash Credit Card Insurance Others

Person responsible for financial matters

Self Spouse Parent/Guardian Others

If Different From Above

First Name

Initial Name

Last Name

Date Of Birth

Address

Apt.

City

Prov.

Postal Code

Home Tel

Work Tel

Primary Insurance

Driver's LIC

ID#

Ins. Company

Employer

Policy Holder

Date Of Birth

Policy

Certificate#

Secondary Insurance

Ins. Company

Employer

Policy Holder

Date Of Birth

Policy

Certificate#

Medical History

1. Are you presently under the care of a physician? If so,explain.

Yes No

2. Have you ever been hospitalized? Explain.

Yes No

3. When was you last medical checkup?

4. Are you taking any drug or medication at this time?

Yes No

5. Do you have any allergies?

Please tick appropriate boxes.

None Local Anesthetic Latex/Rubber Antibiotics Others

6. Do you bruise easily or have prolonged bleeding?

Yes No

7. Do you have or have you ever had asthma?

Yes No

8. Do you have or have you ever had any heart or blood pressure problems?

Yes No

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart)i.e. infective endocarditis), a heart condiiton from birth (i.e. congenital heart disease) or a heart transplant?

Yes No

10. Do you have a prosthetic or artificial joint?

Yes No

11. Do you have any condition or therapies that could affect your immune system. e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

Yes No

12. Have you ever had hepatitis, jaundice or liver disease?

Yes No

13. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)

Yes No

14. Do you smoke or chew tobacco products? How much per day?

Yes No

15. Have you ever fainted, had shortness of breathe or chest pains?

Yes No

16. WOMEN

Are you pregnant?

Yes No

Using Birth Control?

Yes No

Reached menopause?

Yes No

17. Do you have or have you ever had any of the following? Please tick appropriate boxes.

18. Are there any conditions or diseases not listed above that you have or had? If so what?

Dental History

1. What is the reason for today's visit?

Emergency Examination Others

2. How frequently do you see a dentist?

3-6 months Annually Others

3. When was your last dental visit?

Last X-ray?

4. How often do you brush per day

Floss?

Use anti-bacterial rinse?

5. Are your teeth sensitive to:

Cold Sweets Heat Others

Others

6. Do your gums bleed when:

Brushing Flossing Never

7. Do your jaws crack or pop when you open widely?

Yes No

8. Do you grind or clench your teeth?

Yes No

9. Are you nervous during dental treatment?

Yes No

10. Would you prefer sedation for dental treatment?

Yes No

11. Have you ever had any problems with previous dental treatments?

Yes No

Specify

12. Have you ever had any of the following:

Bridgework Crowns or Caps Full or Partial Dentures Orthodontic (braces) Periodontal (Gums) Treatment Root Canal

13. Are you satisfied with your teeth?

Yes No

Specify

General Release
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I hjave completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is 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 dependents. I assume all responsibility fro fees associated with my dental treatment or dental diagnostic procedures.

Signature/Self/parent/Guardian

Print Name

Date

Dentist Signature

Print Name

Date

Medication List

Are you currently taking any medications?

Yes No

If Yes, Please list your medications:

1. Medication

2. Medication

3. Medication

4. Medication

5. Medication

6. Medication

7. Medication

8. Medication

9. Medication

10. Medication

Signature

Date

Dentist Signature

Payment Policy

The full payment for services rendered within the office is expected at the end of each appointment. For your convenience, our office will send an electronic estimate ahead of time to your insurance company and then bill directly to them upon completion of the procedure. If the claim is not processed electronically, then we will ask for your signature on the appropriate forms so we can mail out a hard copy of the dental claim to your insurance.

For any charges that are not covered by your insurance or if you do not have dental insurance, you will be responsible for the remaining cost. We accept Visa, Mastercard, American Express, Debit, and Cash.

Cancellation Policy

Please always arrive on time for your appointment. If you are running a few minutes late, please call our office to let us know. If you are significantly delayed, we may only be able to complete a partial treatment or may even have to ask you to reschedule depending on the remaining time left before the following patient’s appointment.

We require at least 48 hours (or 2 business days) notice to cancel or reschedule your appointment. This allows us time to fill in the schedule in an attempt not to waste our dentists’ and hygienists’ time. We will try to be understanding to last minute cancellations for unexpected medical or personal emergencies, but repeat occurrences of last−minute cancellations or no−shows to your appointments will incur a $50.00 fee for the disruption.

I have read and understand the terms indicated above.

Signature

Date

COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Our office understands the importance of protecting your personal information. We will collect, use and disclose information about you for the following purposes:

Enable us to contact you (your child) to book and confirm appointments.
To advise you of treatment options
To communicate with other health−care providers, including medical and dental specialists and general practitioners
To comply with legal and regulatory requirements, including the delivery of patient’s charts and records to the Royal College or Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulatory health professions act.
To comply with agreements/undertakings entered into voluntarily by Dr. Ngoc D Steve Van, Dr. Puneet Gill or their associates 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 prepare material for the Health Professions Appeal and Review Board
To process credit card payments
To collect unpaid accounts.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the consequences of that decision, and the process.

By signing the consent section of this form, you have agreed that you have given your informed consent to collection, use and/or disclosure of your personal information for the purposes that are listen.

Patient Consent

I have reviewed the above information that explains how your office will use my personal information. I agree that Dr. Ngoc D Steve Van, Dr. Puneet Gill or their associates can collect, use and disclose personal information as set out above in the information about the office’s privacy policies according to the requirements of the Regulated Health Professions Act, the Royal College of Dental Surgeons and privacy legislations.

Print Name

Signature

Date

Signature Witness

New Patient Form

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