Cosmetic Dentistry Services at Nordic Dentistry - cosmetic dentistry Kitchener ON

New Patients Form

Title:

First Name:(Required)

Last Name:(Required)

How did you find us(Required)

DATE OF BIRTH (D/M/Y):(Required)

Age:

Gender

Male

Female

Phone (Home)

Phone (Cell)

Phone (Work)

Home Address:(Required)

City :(Required)

App/Unit

Province:(Required)

Postal Code:(Required)

Occupation:

Employer:

Health card number:

Name of Family Doctor:

Phone:

Address:

Name of your Specialist:

Phone:

Address:

In case of EMERGENCY, We should notify:

Name:

Relationship:

Phone:

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

Policy holder Contact Phone Number:

Group Policy/plan Number:

I.D./Certificate Number:

Marital Status:

Single

Married/Common Law

Other

Insurance Company Name:

Secondary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

Policy holder Contact Phone Number:

Group Policy/plan Number:

I.D./Certificate Number:

Marital Status:

Single

Married/Common Law

Other

Insurance Company Name:

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information in the medical and dental history 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 fill in the entire form.

Do you have or have you ever had any of the following:

Are there any conditions or diseases not listed above that you have or have had?

Yes

Not Sure

Please explain

Do you have any allergies or sensitivities to any:

Medications:

Latex/rubber products:

Other: (e .g . hay fever, seasonal/environmental, foods):

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

Yes

Not Sure

please list them:

Has your physician ever told you to take antibiotics prior to dental procdure?

Yes

Not Sure

please mention the reason for antibiotic:

Have you ever experienced complications following a medical or dental procedure?

Yes

Are you currently being treated for any medical condition or have you been treated within the past year?

Yes

Not Sure

please explain?

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 condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes

Not Sure

please explain:

Have you ever been hospitalized for any illnesses or operations?

Yes

please explain:

Do you identify as a patient with a disability?

Yes

Are you Pregnant?

Yes

Not Sure

what is the expected delivery date?

Are you breastfeeding?

Yes

Do you smoke or chew tobacco products?

Yes

Has there been any change in your general health in the past year?

Yes

please explain:

To the best of my knowledge, the above information is correct.

Patient/Parent/Guardian Signature:(Required)

Date

Dentist Notes:

Dental History Questionnaire

1 . What is the reason for your visit today? Are you currently experiencing any dental problems?

2 . Have you been seeing a dentist regularly?

Yes

why not?

3 . Are you nervous during dental visits?

Yes

4 . Have you had a bad experience or complications during dental treatment?

Yes

5.1. When was your last dental visit?

5.2. What was done at that appointment?

6.1. How often do you brush your teeth?

6.2. How often do you floss?

7. Do your gums bleed when you brush or floss?

Yes

Not Sure

8 . Do you feel that you have bad breath?

Yes

Not Sure

9 . Are you happy with the appearance of your teeth?

Yes

10 . Are you happy with your smile?

Yes

11.1. Have you ever whitened your teeth?

Yes

11.2. Are you interested in whitening?

Yes

12 . Is there anything about the appearance of your teeth that you would like to change?

Yes

please explain:

13 . Are you self conscious about your teeth?

Yes

14 . Do you have any problems with your jaw (clicking, limited movement, pain)?

Yes

Not Sure

15 . Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?

Yes

16 . What is the most important thing to you about your future smile and dental health?

Patient/Parent/Guardian Signature:(Required)

Date(Required)

Privacy Consent

I allow and provide consent to Nordic Dentistry to collect, use and disclose information about me for the following purposes:
To deliver safe and efficient patient care
To identify and to ensure continuous, high-quality services
To assess my dental health needs
To advise me of treatment options
To enable Nordic Dentistry to contact me directly
To establish and maintain communication with me
To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care
To allow Nordic Dentistry to efficiently follow-up for treatment, care, and billing For teaching and demonstrating purposes on an anonymous basis
To complete and submit electronic and/or paper dental claims for third party adjudication, pre-approval where necessary, and payment
To permit dentists, practice brokers and/or advisors to evaluate the dental practice and conduct an audit in preparation for practice sale
To invoice for goods and services
To process credit card payments when there is a balance outstanding or when I call in and provide telephone authorization
To provide Nordic Dentistry with insurance details, so we may receive a dental breakdown of the coverage. You are also responsible for any differences not paid by the insurance company, on the same day as the service is rendered.
o If a patient’s account falls into arrears all reasonable collection fees will be the responsibility of the account holder, in addition to the arrears and possible service fee.
I authorize Nordic Dentistry to post/advertise pictures within the office and on social media of myself or my child/dependent.
I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.
This authorization shall continue in effect until authorize the communication of information related to the coverage of services described to the named dentist.

Agree(Required)

Agree To Privacy

Name(Required)

First Last

Signature(Required)

New Patients Form

Insurance Information

Medical History

Dental History Questionnaire

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