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Online Patient Form

Patient Name: FIRST MIDDLE LAST
Date of Birth: Month/Day/Year Age: yrs. Gender: MaleFemale
Address:
CITY PROVINCE POSTAL CODE
Home #: Work #:
Cell #: Cell Network
E-mail:    
General Dentist: Physician:
HOW DID YOU HEAR ABOUT OUR OFFICE? Please tick all that apply.
Community Magazine:Yellow Pages:Airdrie Echo:Internet:Signage:Dentist:Patient:Staff:
If Dentist, Patient, Staff or Other Please Provide Name
I Have a Family Member who was or is a Patient Here
IF PATIENT IS MINOR, PLEASE GIVE PARENT INFORMATION
Mother: Day Contact #
Father: Day Contact #
Other: Day Contact #
RESPONSIBLE PARTY INFORMATION
Name: FIRST MIDDLE LAST
Address: CITY POSTAL CODE
Home #: Work #:
Cell #: Relationship to Patient:
Place of Employment: Occupation:
INSURANCE INFORMATION (You will need this information to claim)
Does Your Insurance Benefit Cover Orthodontic Treatment? YesNo
(1) Name of Primary Subscriber: Phone #:
Employers Name: Phone #
Insurance Company Name: Date of Birth:
Group/Policy #: ID #:
Address (If Subscribers Address is Different Then Above)
(2) Name of Secondary Subscriber: Phone #:
Employers Name: Phone #
Insurance Company Name: Date of Birth:
Group/Policy #: ID #:
Address (If Subscribers Address is Different Then Above)
Medical History
What is your main concern? SpacesCrowdingAppearanceReferralJaw PainTooth Wear
Are you presently in good health?
Are you presently under a physician’s care?
Have you had an illness, operation or been hospitalized in the last 5 years?
Do you have an artificial joint, heart valve replacement or vascular graft?
Have you ever been told that you require antibiotics prior to dental treatment?
Do you see a dentist for regular preventative care?
Have you had, or currently have:
Rheumatic Fever Diabetes
Heart Condition (MVP, Murmur) Asthma
Blood Transfusion Hay Fever / Sinus problems
Blood Disorders (Anemia etc.) Tuberculosis
Bruise easily Prolonged bleeding
Hepatitis / Jaundice / liver problems Pneumonia
Kidney disorder Problems with immune system
Bone disorder Tumors or growths
Nervous disorder Sexually transmitted disease
Seizures or Epilepsy HIV or AIDS
Do you smoke Radiation or Chemotherapy
Prolonged cough Experienced frequent diarrhea
Undiagnosed rash    
Hereditary conditions we should be aware of    
If Yes, Please Describe:
Are you taking any form of medication or non-prescription supplement?
If Yes, Please List:
Do you have any allergies?
If Yes, Please List:
Are you allergic to, or had a reaction to? Medication
    Latex
    Metal (nickel, etc)
If you are a female patient, please fill out the info below
Are you taking hormonal medication Oral Contraceptives
Are you pregnant? Date of delivery?
Are there any other conditions concerning your health that we should be aware of
If Yes, Please Describe:

Personal Information Consent

We are 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 we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted by law.

We collect information from our patients such as names, home addresses, work addresses, home phone number, work phone number, and e-mail addresses. (Collectively referred to as Contact Information) Contact information is collected and used for the following purposes:

  • To open and update patient files
  • To invoice patients for services, to process credit card payments, or to collect unpaid accounts
  • To process claims for payment or reimbursements from third-party health benefit providers and insurance companies
  • To send reminders to patients concerning the need for further orthodontic treatment
  • To send patients informational material about our orthodontic practice

Contact information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

Financial information may be collected in order to make arrangements for payment of dental services.

We collect information from our patients about health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patient’s Medical information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic treatment.

Patient’s Medical Information is disclosed:

  • To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patients behalf
  • To dentists and dentist specialists, where we are seeking a second opinion and the patient has consented to us obtaining a second opinion
  • To other dentists and dental specialists if the patient, with consent, has been referred by us to the other dentist or dental specialist for treatment
  • To other dentists and dental specialists where those dentists have asked us, with consent of the patient to provide a second opinion
  • To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentist and Orthodontists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the office. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat or to continue treating you if you revoke this consent.

I consent to the collection, use and disclosure of my personal information as set out above. I further consent to include electronic communication between the office and yourself, as well as 3rd party insurance and other dental and health professionals as needed to communicate and make treatment decisions. The electronic communication can and may include non-encrypted email, fax and text messaging.

Your information is being submitted securely and will not be shared or sold. I consent to receive electronic correspondence.

Date Patient’s Printed Name Indicate Consent