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4-575 River Glen Blvd., Oakville, ON 905 257 0002 info@riverglendental.ca

Welcome to River Glen Dental

Personal Info

Patient contact information

Mr.

Mrs.

Ms.

Miss.

Dr.

Gender

Male

Female

Nonbinary

Name

Prefers to be called

DOB

MM

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DD

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YYYY

Cell Phone #:

Home Phone #:

Email:

Address

Person responsible for the account:

Employer:

Occupation:

Family Physician:

Phone Number:

In case of an emergency please notify:

Relationship:

Phone Number:

Primary Insurance Company:

Group Policy/Plan #:

Certificate/ID #:

Policy Holder's First / Last name:

DOB:

MM

/

DD

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YYYY

Secondary Insurance Company:

Group Policy/Plan #:

Certificate/ID #:

Policy Holder's First / Last name:

DOB:

MM

/

DD

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YYYY

Preferred appointment days:

Monday

Tuesday

Wednesday

Thursday

Saturday

Preferred appointment times:

Any

Morning

Afternoon

Evening

Preferred contact/appointment reminder method : ( select all that apply )

Phone call

Text

Email

Another patient, family or friend

Please specify source:

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Medical History

The following information in required by the dentist to assist in proper diagnosis and treatment.

Have you ever had a serious illness requiring hospitalization or extensive medical care?
If yes, please explain:

Yes

No

Are you presently under the care of a physician?
If yes, please explain:

Yes

No

Would you consider yourself to be in general good health?
If not, please explain:

Yes

No

When was your last physical examination?

Do you have any allergies? (e.g. penicillin, latex etc)
If yes, please specify:

Yes

No

Have you ever experienced an unusual reaction to any of the following? Local anaesthesia (freezing), aspirin, penicillin, codeine, sulpha drugs, barbiturates (sleeping pills), or any other medicine?
If yes, please explain:

Yes

No

Do you bruise easily or bleed abnormally?
If yes, please specify:

Yes

No

Have you ever had any organ or medical implants?
If yes, please specify:

Yes

No

Do you require premedication?

Yes

No

WOMEN ONLY:
Are you pregnant or suspect you may be? If yes, what month are you in?

Yes

No

Are you taking contraceptive pills?

Yes

No

Are you nursing?

Yes

No

Do you have or have you had any of the following medical conditions listed below?

Anemia

Emphysema

HIV/AIDS

Multiple Sclerosis

Angina

Epilepsy/Seizures

Hives

Organ/Medical Implants

Arthritis/Rheumatism

Fainting/Dizzy spells

Hyper (hypo) Glycemia

Rheumatic Fever

Asthma

Glaucoma

Jaundice

Sickle Cell Disease

Blood Disease

Hay fever

Joint Replacement

Sinus Trouble

Blood Pressure (high)

Head Injury

Kidney Disease

Shortness of breath

Blood Pressure (low)

Heart Attack

Liver Disease

Stroke

Cancer

Heart Disease

Lung Disease

Stomach/Intestinal problems

Cardiac Pacemaker

Heart Murmur

Lupus

Swollen Ankles

Cold Sores

Hepatitis A

Malignant Hyperthermia

Tuberculosis

Cortisone/Steroid Therapy

Diabetes

Drug/Alcohol Dependency

Hepatitis B

Hepatitis C

Herpes

Mental/Nervous Disorder

Migraines/Headaches

Mitral Valve Prolapse

Venereal Disease

Do you have or have you had any other medical condition not listed above?

Do you use any prescription, non-prescription drugs or herbal supplements regularly?

Please list below:

Yes

No

Medical Condition:

Medication

Dosage:

Medical Condition:

Medication:

Dosage:

Medical Condition:

Medication:

Dosage:

Medical Condition:

Medication:

Dosage:

Medical Condition:

Medication:

Dosage:

If more, please list Medical Condition, Medication and Dosage:

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Dental History

Reason for today's visit?

Are you presently having dental pain?

Yes

No

Is there a dental problem you would like to take care of as soon as possible? If yes, please specify:

Yes

No

What is the name of your previous dentist?

How frequently do you see your dentist?

When did you first start seeing the dentist (what age)(where)?

Date of last dental visit:

Last cleaning:

Last full mouth series of x rays:

How often do you brush your teeth?

How often do you floss your teeth?

Do your gums bleed easily?

Yes

No

Are your teeth sensitive to heat?

Yes

No

Are your teeth sensitive to other things?

Yes

No

Do you experience bad breath at times?

Yes

No

Have you ever had any injury, surgery or x ray therapy to your face or jaws?

Yes

No

Do you have TMJ problems?

Yes

No

Does any part of your mouth hurt when clenched?

Yes

No

Does your jaw crack or pop when open widely?

Yes

No

Do you grind or clench your teeth during the day or night?

Yes

No

Have you ever had Braces, Oral surgery, gum treatment, or a root canal? If yes, please specify:

Yes

No

Do you smoke? If yes, how many per day?

Yes

No

Do you or is there any family history of snoring? If yes, please specify:

Yes

No

Have you experienced any growths or sore spots in your mouth? If yes, please specify where:

Yes

No

Have you ever had an unfavourable experience or previous problems with dental treatment? If yes, please specify:

Yes

No

Are you satisfied with the appearance of your teeth? Please specify:

Yes

No

Do you have any other dental concerns?

Yes

No

Patient Release

I, the undersigned certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

Signature of Patient, Parent or Guardian:

Date

MM

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DD

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YYYY

For office use only:

Signature of Reviewing Dentist:

Date

MM

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YYYY

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Patient Privacy Information and Consent Form

As outlined in the Ontario Health Information Privacy Act we are obligated to have each patient sign a consent form allowing us to collect, use and disclose person information as outlined in the specific guidelines.

Your privacy is of utmost importance to us and we are committed to ensuring the collection and use of your personal information is dealt with responsibly by all members of our team. If at any time you have any questions or concerns about our code of privacy, please feel free to discuss it with Dr. Sardana or our patient coordinators.

Reasons for collecting and disclosing personal information include:

- Collecting information necessary for your dental treatment.
- Keeping accurate up to date records needed for contact information, billing accounts, payment collection and insurance information.
- To assess your health needs and risks.
- To communicate to other practitioners regarding referrals and ongoing treatment.
- To comply with legal regulatory requirements as outlined by the Royal College of Dental Surgeons of Ontario and the Regulated Health Professions Act.
- To disclose information to insurance carriers as requested on a need to know basis.

Terms of Service

I consent that the staff members of River Glen Dental Offcie may collect, use and disclose personal information as outlined above for myself or my child.

Patient's Name (please print):

Signature Patient/Guardian

Date

MM

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DD

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YYYY

For office use only:
Witness:

Date

MM

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DD

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YYYY

Insurance Privacy

In July 2003 the Royal College of Dental Surgeons passed a privacy Act, which prevents all dental offices from obtaining the insurance details of their patients.

Because of this, it has become necessary for us to ask you, our patients, to keep track of all your insurance details including treatment frequencies and insurance maximums etc. Please be advised that your insurance company does not inform us if there are any changes to your policy nor do we have any way of obtaining such information. If you have any changes to your insurance you must inform us so we are able to complete your claims and estimates correctly. Such changes include Insurance company, policy number, certificate number, change of your personal address or name change.

If we do not hae your correct information this will cause a delay in you receiving your benefits.

Any estimates sent to your insurance company on your behalf should be reviewed and discussed by yourself and one of our patient coordinators prior to the scheduled treatment date. Prebooked appointments will not be confirmed until we receive and discuss this information. If estimate answers are not received by the patient in a timely manner, it is the patient's responsibility to notify our office prior to the scheduled appointments.

Payment

Please be aware that payment is due as services are rendered. We accept Cash, Debit, Visa, Master Card or Amex. Please note once we have submitted your insurance claim your insurance company will reimburse you directly for the benefits allowed by your carrier.

For all major restorative treatment, we require payment for the lab fee at the initial appointment. Final billing for the treatment and insurance submission will take place on the insertion or completion date.

Cancellation Policy

Your appointment is especially reserved for you. If you cannot keep your appointment, we require at least 2 business days notice. If we are not notified before this time you may be billed $50 per appointment for the lost time. Your understanding is appreciated.

I have been given the opportunity to ask any questions and such questions have been explained to me. I have read and understand the office policies.

Patient's Name: (please print)

Signature of Patient or Guardian:

Date

MM

/

DD

/

YYYY

Witness

Date

MM

/

DD

/

YYYY

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