New Patient Form

Waterloo Emergency Dental Centre

258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505

Today's Date*

Patient Name*

First Middle Last

Gender

Family Status*

Date of Birth*

DD

MM

YYYY

Age*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Email*

Work Phone

Extension Number

Health Card Number*

Family Physician*

First Last

Physician's Phone*

In Case of Emergency, We should notify:*

First Last

Relationship*

Phone*

Responsible Party Information Insurance Information

*Please note, patient is responsible with providing us a copy of their insurance card(s).*

Party responsible for payment*

Primary

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

First Last

Is Insured a patient?

Patient's relationship to insured

Insured's Birth Date

DD

MM

YYYY

Age

Secondary

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

First Last

Is Insured a patient?

Patient's relationship to insured

Insured's Birth Date

DD

MM

YYYY

Age

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic

Yes
No

Which Antibiotic

Aspirin/Advil

Yes
No

Codeine

Yes
No

Latex

Yes
No

Local Anesthetics/Novocain

Yes
No

Other

Yes
No

Please Specify

Do you take blood thinners (e.g Coumadin, Plavix, etc.)*

Specify the date and score of most recent INR

Do you take any other medications, vitamins or supplements*

Name of medication

What condition you take it for

(List any additional meds you take on separate sheet)

Other Medical Conditions

where do you keep your inhaler?

Surgery Details

Specify any of the above conditions

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

What are they?

Have you ever had any complications following dental treatment?*

Please explain

Are you covered under Ontario Disability (ODSP)*

Please specify your disability

Are you pregnant or is it possible you are pregnant?*

Due Date

DD

MM

YYYY

Are you now under the care of a physician, regarding an ongoing medical issue?*

Please explain

Do you have any health problems that need further clarification?*

Please explain

Do you smoke?*

How many cigarettes a day?

When did you quit?

DD

MM

YYYY

Do you use any recreational drugs?*

Please list which kind:

Do you have a prosthetic or artificial joint ?*

Where ?

Do you have or have you ever had replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?*

Referring Patients Name

When was your last dental visit ?*

When did you last have dental x-rays ?*

How often do you floss your teeth ?*

How often do you brush your teeth ?*

Have you been seeing a dentist regularly ?*

Do any of your teeth ache ?*

Do your gums bleed when you brush ?*

Do you have pain when you chew ?*

Do you feel you have bad breath ?*

Please list anything else not mentioned above regarding your past dental history.

Whom may we thank for referring you to our practice ?*

Please specify

Consent for Services & Office Agreement

* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage.

It is my responsibility to ensure that the treatment I request is covered. However, Waterloo Emergency Dental Centre will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Waterloo Emergency Dental Centre has NO knowledge of what is covered by my insurance plan. If I have a booklet, Waterloo Emergency Dental Centre will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Waterloo Emergency Dental Centre will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* Waterloo Emergency Dental Centre also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

* Waterloo Emergency Dental Centre will always make every attempt to see emergency cases promptly.

* Waterloo Emergency Dental Centre will accept Visa, MasterCard, debit and cash.

* Waterloo Emergency Dental Centre will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that Waterloo Emergency Dental Centre has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.

Consent*

I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature of patient, parent or guardian (Type in Your Name)

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