First Name:
Middle Name:
Last Name:
Gender Identity: WomanManOtherPrefer Not to Say
Date of Birth:
Home Address: Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe Select State Select City
Cell Phone:
Home Phone:(Optional)
Email Address:
Occupation:
Company Name:
Driver License Number:
Name of Parents/ Guardian (if under 18 or under guardianship):
Address of Parents / Guardian (if not same as above): Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe Select State Select City
Phone Number of Parents / Guardian (if not same as above)::
Emergency Contact Name:
Relationship:
Contact Number:
Name of Family Physician:
Contact Number of Family Physician:
Family Physician office Address: Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe Select State Select City
Name of First Medical Specialist:
Area of Specialty:
Name of Second Medical Specialist (Optional):
Pharmacy Name:
Pharmacy Contact Number:
Do you have insurance coverage? YesNoNot Sure If yes, please provide following details: (a). Insurance Company Name: (b). Member Name: (c). Member Date of Birth: (d). Policy Number: (e). Certificate Number:
How did you come to know about us? (This information helps us better serve our community and thank the person/source who referred us to you.) Flyer in MailGoogle reviewsLive in neighborhoodWebsiteFriend/ FamilyOther If Friend/ Family (Please provide their name) If Other
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 fill in the entire form.
1. Are you currently being treated for any medical condition or have you been treated within the past year? YesNoNot Sure If Yes Explain Here:
2. When was your last complete medical examination?
3. Has there been any change in your general health in the past year? YesNoNot Sure
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? YesNoNot Sure
5. Do you have any allergies?* If yes, please list them using the categories below: YesNoNot Sure
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. YesNoNot Sure
7. Do you have or have you ever had asthma? YesNoNot Sure
8. Do you have or have you ever had any heart or blood pressure problems? YesNoNot Sure
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 condition from birth (i.e. congenital heart disease) or a heart transplant? YesNoNot Sure
10. Do you have a prosthetic or artificial joint? YesNoNot Sure
11. Do you have any conditions or therapies that could affect your immune system? (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy) YesNoNot Sure
12. Have you ever had hepatitis, jaundice or liver disease? YesNoNot Sure
13. Do you have a bleeding problem or bleeding disorder? YesNoNot Sure
14. Have you ever been hospitalized for any illnesses or operations? YesNoNot Sure
15. Do you have or have you ever had any of the following?* Alzheimer's DiseaseDiabetesHerpesRheumatic FeverAnaphylaxisDrug AddictionHigh Blood PressureRheumatismAnemiaEasily WindedHIV/AIDSScarlet FeverAnginaEmphysemaHives or RashShinglesArthritis/GoutEpilepsy/SeizuresHypoglycemiaSickle Cell DiseaseArtificial Heart ValveExcessive BleedingIrregular HeartbeatSinus TroubleArtificial JointExcessive ThirstKidney ProblemsSpina BifidaAsthmaFainting SpellsLeukemiaStomach/Intestinal DiseaseBlood DiseaseFrequent CoughLiver DiseaseStrokeBlood TransfusionFrequent DiarrheaLow Blood PressureSwelling of LimbsBreathing ProblemFrequent HeadachesLung DiseaseThyroid DiseaseBruise EasilyGlaucomaMitral Valve ProlapseTonsillitisCancerHay FeverPain in Jaw JointsTuberculosisChemotherapyHeart AttackParathyroid DiseaseTumors or GrowthsChest PainsHeart MurmurPsychiatric CareUlcersCold SoresHeart Pace MakerRadiation TreatmentsVenereal DiseaseCongenital Heart DisorderHeart TroubleRecent Weight LossYellow JaundiceConvulsionsHemophiliaRenal DialysisCortisone MedsHepatitis A/B/C
16. Are there any conditions or diseases not listed above that you have or have had?* If yes, please explain. YesNoNot Sure
17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? YesNoNot Sure
18. Do you smoke or chew tobacco products? YesNoNot Sure
19. Have you ever had a previous reaction to metal or metal jewellery? YesNoNot Sure
20. Have you ever had an adverse reaction to dental freezing, general anaesthetic, penicillin, codeine, aspirin, or other drugs? (circle those that apply) YesNoNot Sure
21. Do you suffer from canker sores or cold sores? YesNoNot Sure
22. Have you ever fainted? What were the circumstances? YesNoNot Sure
23.Have you ever experienced any recent unexplained weight change, or increased thirst, appetite, frequency of urination? YesNoNot Sure
24. Have you ever had a shortness of breath or pains in your chest? YesNoNot Sure
25. Do you have a heart condition of any kind? (angina pectoris, arrhythmias, or previous heart attack – please circle if any condition apply) YesNoNot Sure
26. Have you had any organ transplants or joint replacements? If yes, when? YesNoNot Sure
27. Do you have a prosthetic heart valve or wear a pacemaker? YesNoNot Sure
28. Have you been told by your medical doctor that you need to take antibiotics before dental treatment? YesNoNot Sure
29. Are you on any special diet? (e.g., salt restricted diet) YesNoNot Sure
30. Do you wear contact lenses? YesNoNot Sure
31. Do you currently use cannabis for non-medical (recreational) purposes, including smoked, vaped, ingested, or topical forms? YesNoNot Sure If yes, please indicate frequency of use:
DailySeveral times per weekWeeklyMonthlyLess than monthly / occasional
32. Do you currently use injectable medications for weight management or metabolic conditions whether prescribed or non-prescribed?
If yes, please indicate: Medication name: Frequency of administration: DailyWeeklyBi-weeklyOther
Date of last dose
Prescribed by a regulated healthcare provider? YesNoNot Sure
33. Do you identify as a patient with a disability? YesNoNot Sure
If Yes Explain Here:
34. Are you pregnant? If yes, how many months? YesNoNot Sure If pregnant, what is the expected delivery date?
35. Are you taking birth control pills? YesNoNot Sure
36. Are you menopausal or post-menopausal? If yes, are you on hormone replacement therapy? YesNoNot Sure
37. Are you breastfeeding? YesNoNot Sure
38. Are you nervous during dental treatment? YesNoNot Sure
39. Have you ever had a negative dental experience? YesNoNot Sure
40. Are you generally tense during dental visits? YesNoNot Sure
Periodontal History
41. Are you aware of bad breath or a bad taste in your mouth? YesNoNot Sure
42. Does food routinely get wedged between your teeth? YesNoNot Sure
43. Does your mouth tend to be dry? YesNoNot Sure
44. Are your parents or siblings missing any of their natural teeth? YesNoNot Sure
Habits
45. Do you smoke cigars or cigarettes? Recreational smoking? (circle all that apply) If so, how many per week?
46. Do you chew on pencils, gum, ice cubes, or popcorn kernels? Etc. (circle all that apply) YesNoNot Sure
47. Do you bite your fingernails, pins, or use a pipe? Etc. (circle all that apply) YesNoNot Sure
48. Do you drink coffee, tea, or cola drinks? YesNoNot Sure
49. Do you bite your lips or cheeks regularly? YesNoNot Sure
50. Do you breathe through your mouth when awake or asleep? YesNoNot Sure
51. Are you aware if you snore during sleep? YesNoNot Sure
52. Do you participate in any sports? YesNoNot Sure
Aesthetics 53. Are you satisfied with the appearance of your teeth and smile? YesNoNot Sure
54. Would you be interested in knowing about veneers, bonding, tooth whitening, implants, ortho, Invisalign, and other cosmetic options? YesNoNot Sure
55. On a scale of 1 to 5, please rate your current dental health. Excellent 12345
56. What priority do you place on your dental health? Highest Priority 12345
I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge, and I have not omitted any pertinent information. Should the need arise, I allow my medical doctor to be consulted. I understand that I am financially responsible to the dentist for all necessary treatment.
Signatures Patient Signature:
Dentist Signature:
Name of Parent/ Legal Guardian (for minor patients that are under the age of 18)
Signature of Parent/ Legal Guardian:
Dentist Notes:
Privacy of your personal information is an essential part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using, and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide these services to our patients.
All staff members who encounter your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information. In this consent form, we have outlined our office policy to ensure that:
Only necessary information is collected about you.
We only share information with your consent.
Storage, retention and destruction of your personal information complies with existing legislation and privacy protocols.
Our privacy protocols comply with privacy legislation, standards of our regulatory body and the law.
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is using and disclosing your information.
This office will collect, use, and disclose information about you for the following purposes:
To communicate with other treating health care providers including specialists and referring doctors
To allow us to distribute health care information and to book and confirm appointments.
To allow us to efficiently follow-up for treatment, care, and billing.
To complete and submit claims for third party adjudication and payment.
To comply with legal and regulatory requirements, including the delivery of patients’ chart and records to the governing bodies when required according to the Regulated Health Professions Act.
To comply with agreements/undertakings entered voluntarily by the member with governing bodies including the delivery and/or review of patients’ charts and for regulatory and monitoring purposes.
To allow potential purchasers, practice brokers/ advisors to conduct an audit in preparation for practice sale.
To deliver your charts and records to the office’s insurance carrier to enable insurance company to assess liabilities and quantify damages, if any.
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 and 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 information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of Personal Health Information Protection Act (PHIPA) and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may advise you if such a release is inappropriate.
You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.
Put Your Initials
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I agree that Keele and Sheppard Dentistry can collect, use and disclose personal information about (Patient’s name) as set above in the information about the office’s privacy policy.
Name of Patient
Signature of Patient
Signature of Parent/ Legal Guardian
Date
Name of Parent / Legal Guardian (for minor patients under 18)
I agree to the Privacy Policy and consent to the collection, use and disclosure of my personal information as described above.
