Patient Forms Registration Form Office Policyappointments you have booked. All appointments are considered confirmed unless you have called to cancel or change your appointment. It is your responsibility to remember your scheduled appointment. APPOINTMENTS - A full 2 OFFICE BUSINESS DAY notice is required to change or cancel any schedule appointments. – To avoid a cancellation fee. Cancellations that are left on office voice mail will not be accepted to change your scheduled appointment. DENTAL INSURANCE: Your insurance company may not give our office information regarding your contract policies; this is under the Policyholder’s Privacy Act. When our office is checking your insurance eligibility, your insurance (if they disclose your insurance information to our office) is for the date we called and your insurance will give us the information they have on file. Due to limits and frequencies under your plan contract our office may not be able determine if all dental treatment may be covered under your plan contract due to this privacy act. If we have problems with receiving payment from your dental plan for any treatment rendered, you understand you will pay the dentist directly and get reimbursed from your dental insurance. Contact your insurance company or your plan benefits department if you need information regarding your policy. OFFICE POLICY REGARDING AMALGAM (SILVER) VS COMPOSITE (WHITE) FILLINGS: Composite (white) fillings on permanent molars are not covered under some plan contract. Insurance company rarely covers for composite (white) filling on back molar teeth. Your insurance plan will cover the equivalency of an amalgam (silver) filling. There is a cost difference for this type of restoration which varies from $40.00 to $160.00 per tooth. This is to inform every patient: Our office does not do “AMALGAM/MERCURY” fillings. You understand should you want to do this type of filling we will provide you a number to the BC Dental Association and if possible not guaranteed they may be able to refer to a dentist that does “amalgam/mercury” fillings. ELECTRONIC BILLING You are authorizing my dental office to send my dental claims to my insurance company electronically. PATIENT RESPONSIBILITY Inform us of medical changes, allergies, address and telephone changes and dental plan changes. Dental treatment may not be covered or may exceed your plan benefits. You understand that you are financially responsible to the dentist for the entire treatment rendered. Payment for any treatment not covered needs to be paid when services rendered, unless payment plan has been previously arranged by you and the dentist. I have read and fully understand the above office policy regarding my dental insurance & my patient responsibility.Today's Date (DD/MM/YYYY)* Patient Full Name* Primary applicant please sign inside the box* Personal InformationFirst Name* Last Name* Middle Initial Title Mr. Miss. Mst. Ms. Mrs. Dr. Is this your legal name? Yes No Birth Date (DD/MM/YYYY)* Sex Female Male Street Address* City* Province* Postal Code* E-mail* Primary Phone Number* Secondary Phone Number Job Title/Occupation* Current Employer/Company Referred to clinic by (please check one): Family/friend Website Family Dentist Other If Other Name of referral: Other family members seen here: Insurance Information (Please give your insurance card to the receptionist)Are you covered with dental insurance? Yes No Do you have dual (secondary) insurance? Yes No Name of Primary insurance (if applicable): Subscriber’s name: Subscriber’s Birthdate: Group no.: ID or certificate no.: Patient’s relationship to subscriber: Self Spouse Child Other Name of Secondary insurance (if applicable): Subscriber’s name: Subscriber’s Birthdate: Group no.: ID or certificate no.: Patient’s relationship to subscriber: Self Spouse Child Other In Case Of EmergencyName of next of kin or friend: Relationship to patient: Home phone no.: Work phone no.: Consent* I certify that I have read and understand the above information to the best of my knowledge. The above questions and the health questionnaire have been accurately answered.I understand that providing incorrect information cans be dangerous to my health. I authorize the dentist too release any information including the diagnosis and the records of any treatment or examination rendered to me/or my child during the period of such dental care to third party payors and/or Health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand that I am financially responsible to my dentist for the entire treatment rendered on my behalf or my dependents.Today's Date (DD/MM/YYYY)* Primary applicant please sign inside the box* Health QuestionnaireFirst Name* Last Name* Middle Initial Date of Birth (DD/MM/YYYY) Best Contact #: E-mail Address: Have you been examined and /or treated by a physician within the last year? Yes No If yes, When? Physician’s Name: Physician’s Phone: Have you ever been seriously ill or hospitalized? Yes No If yes, When? Do you require any antibiotic coverage before any dental treatment? Yes No Are you on blood thinners? Yes No If YES the medication you are taking: Please check (√) if you have ever had any of the following: Angina - Chest Pain Arthritis Artifical Joints (Hip/Knee) Ashtma Bruise easy Cancer Radiation / chemo treatment Cold sores Congenital heart condition Cortisone/steroid therapy Difficulty swallowing Earaches Feel thirsty much of the time Frequent indigestion/vomiting Heart attach or Stroke Heart murmur / palpitations High risk group of AIDS/HIV Infectious/communicable disease Inflammatory rhematism Lung/breathing problems Mitral Valve Prolapse Nervous / Mental / Depression Transplants i.e. Hip/Knee Pacemaker/artifical valves Prolong bleeding after injury Persistent cough Painful swollen joints Rheumatic fever Recent change in appetite Severe headaches Sinus trouble / Sore throats Stomach / intestinal problems Tendency to faint Trouble hearing Tumors or growth Thyroid problem Venereal Disease Drug or Alcohol Addiction Blood Pressure Problems Yes No Type High Low Diabetes Yes No Type Type 1 Type 2 Liver disease/ Hepatitis: Yes No Type Do You Smoke? Yes No Sensitivites/Allergies Aspirin Codeine Advil - Ibuprofen Sulfa Tylenol Penicillin Clindamycin/Erythromycin Nitrous Oxide (anaesthetic gas) Latex Other (Not listed) WOMAN ONLY: Are you pregnant? Yes No *MEDICATIONS you are taking? Is there anything else concerning your health not listed that you think the doctor should know about? Yes No When was your last dental visit? Have you had x-ray taken with in the last year? Are you having dental discomfort or dental pain? Have you ever experienced abnormal bleeding associated with previous extraction, surgery or trauma? Yes No How many times do you brush a day? How many times do you floss a day? Do your gums bleed when brush or floss? Never Sometimes Often Do you have any oral habits: clenching, grinding, nail biting, thumb sucking? Yes No Have you ever had professional tooth brushing & flossing instructions? Yes No I am interested in dental sedation. Yes No Have you had and problems with or unpleasant reactions to dental treatment? Yes No Are you happy with the appearance of your teeth? Yes No My primary concerns is: Today's Date (DD/MM/YYYY)* Primary applicant please sign inside the box*
