Form Patient Consent Form I consent for your office to collecting, using and disclosing information about me for the following purposes: To deliver safe and effective patient care To identify and ensure continuously high-quality service To assess your health needs To advise you of treatment options To enable us to contact you To establish and maintain communication with you to distribute healthcare information and book and/or confirm appointments To offer and provide treatment, care, and services in relation to the oral and maxillofacial complex and dental care generally To allow us to efficiently follow up for treatment, care, or billing For teaching and demonstrating purposes on an anonymous basis To complete and submit electronic and/or paper dental claims for third-party adjudication and pre-approval where necessary To permit potential dentists, practice brokers, and/or advisors to evaluate the dental practice and conduct an audit in preparation for the practice sale To invoice for goods and services To process payments If patient accounts fall into arrears, all reasonable collection fees will be the responsibility of the patient, in addition to the arrears. Date *Patient Consent Form *Signature *Start signing your signature hereYour browser does not support e-Signature field.I’m aware that there will be a $50.00 charge when cancelling/rescheduling with Less than 2 business days noticeI authorize the release of my Dental Benefit Plan information, contained in claims and estimates submitted Electronically/by mail. This authorization shall continue to be in effect until contractually terminated by the account holder.Date *Date *SignatureStart signing your signature hereYour browser does not support e-Signature field.Signature of Parent/GuardianStart signing your signature hereYour browser does not support e-Signature field.Welcome To Our Dental OfficeIn order to render optimum health service, it is necessary to become acquainted with the vital information related to each patient. Of course, all information is strictly confidential. Although some questions may seem unimportant at the moment, they may be vital in case of emergency. Therefore, Please answer every question on both sides.Personal InformationDate *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Name *Date of Birth *Age *Street Address *City *Postal CodeHome PhoneOffice PhoneName of EmployerOccupationCellEmail AddressMedical DoctorName of person responsible for this accountDo you have dental insurance?YesNoCompany NamePolicy No.% CoveredI.D. or S.I.N. No.How did you hear about our practice?Medical History1. Have you ever had a serious illness, operation, or been hospitalized?YesNoExplain2. Are you under the care of a physician now for any problem?YesNoExplain3. Have you had a medical examination within the last year?YesNoExplain4. Have you been taking any medication, drugs, or pills presently?YesNoExplain5. Have you ever taken or been given bisphosphonate medication or any of its family?YesNoExplain6. Do you have or have you ever had any of the following?YesNoExplain7. Do you have any allergies?YesNoExplain8. Are you allergic to any medicines or drugs?YesNoExplain9. Have you ever had freezing (local anaesthetic) in your mouth?YesNoAny ill effects from it?10. Do you bleed abnormally?YesNo11. Do you bruise easily?YesNo12. Have you ever fainted?YesNoWhen?13. Do you have shortness of breath?YesNo14. Do you have any chest pains?YesNo15. Do your ankles ever swell?YesNo16. Have you gained or lost excessive weight recently?YesNo17. Have you ever taken cortisone or steroids?YesNo18. Is there any history of family disease?YesNo19. Is there anything that the dentist should know regarding your medical history that has not been mentioned?YesNoExplain20. To the best of your knowledge, are you in good health?YesNoWomen: Are you pregnant?YesNoIn what stage of pregnancyDental History1. Have you ever had a complete dental examination with a full series of dental x-rays within the past 3 years?YesNo2. Last dental visit?What was done?3. Have you had any extractions?YesNoDid you experience prolonged bleeding after?YesNo4. Have you ever had any of the following dental treatments?YesNo5. Are you aware of bad breath or a bad taste in your mouth?YesNo6. Have you ever had a bad experience at the dentist?YesNo7. What is your present dental problem?Dentist SignatureStart signing your signature hereYour browser does not support e-Signature field.DatePatient/Guardian Approval and ConsentSignatureStart signing your signature hereYour browser does not support e-Signature field.DateSend Message How to Find Us Fill up the Form and Ask Your Queries Book an Appointment