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(Required)

Patient Name(Required)

First Middle Last

Date of Birth(Required)

Age(Required)

Family Status(Required)

Gender

What sex were you assigned at birth?

What is your current gender identity?

Specify Current Gender

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!

What pronouns do you prefer that we use when referring to you? (check all that apply)

She/her/hers

He/him/his

They/them/theirs

Other

Specify pronoun

Contact Information

Address(Required)

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

Home Phone

Cell Phone

Email(Required)

Work Phone

Extension Number

Health Card Number

Family Physician(Required)

First Last

Physician's Phone(Required)

In Case of Emergency, We should notify:(Required)

First Last

Relationship(Required)

Phone(Required)

Employer Name

Occupation

Payment Information

Party responsible for payment(Required)

Party Responsible for Payment

First Last

Relationship

Insurance Information

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

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

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

Age

Medical & Dental Information

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

Antibiotic

Yes

Which Antibiotic

Aspirin/Advil

Yes

Codeine

Yes

Latex

Yes

Local Anesthetics/Novocain

Yes

Other

Yes

Please Specify

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

Specify the date and score of most recent INR

Do you take any other medications, vitamins or supplements(Required)

List any medications and dosage (including Herbal)(Required)

Have you ever had any of the following? Please check those that apply:

Neural

Cardiovascular

Pulmonary

Asthma / COPD

Difficulty breathing

Respiratory problems

Tuberculosis

Infectious

AIDS/ HIV

Hepatitis A B C

Venereal Disease

Immune

Hay fever

Allergy

Neoplastic

Cancer

Growths/Tumors

Radiation/Chemo

Digestive

Acid reflux Disease

Stomach Problems

Ulcers

Inflammatory

Arthritis

Rheumatism

Osteoporosis

Other

Where do you keep your inhaler?

Specify any of the above conditions

Surgery Details

If you had any surgeries please specify the surgery date and information.

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

What are they?

Have you ever had any complications following dental treatment?(Required)

Please explain

Have you or anyone related to you ever had problems with local anesthetic?(Required)

Please explain

Are you pregnant or is it possible you are pregnant?(Required)

Due Date

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

Please explain

Do you have any health problems that need further clarification?(Required)

Please explain

Do you smoke?(Required)

How many cigarettes a day?

When did you quit?

Do you use any recreational drugs?(Required)

Please list which kind:

Do you have a prosthetic or artificial joint ?(Required)

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?(Required)

Referring Patients Name

When was your last dental visit ?(Required)

When did you last have dental x-rays ?(Required)

How often do you floss your teeth ?(Required)

How often do you brush your teeth ?(Required)

Have you been seeing a dentist regularly ?(Required)

Do any of your teeth ache ?(Required)

Do your gums bleed when you brush ?(Required)

Do you have pain when you chew ?(Required)

Do you feel you have bad breath ?(Required)

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

Whom may we thank for referring you to our practice ?(Required)

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(Required)

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)

Date(Required)