Emergency Contact Name
We would like to thank who referred you, please list the name of your referral.
Are you being treated for any medical condition at the present or have you been treated within the past year?
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Has there been any change in you health in the past year?
Do you have any allergic condition? E.g. Asthma, skin rash, medications, latex or rubber gloves, hayfever, hives etc.?
Have you ever had a peculiar or adverse reaction to any medication?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a heart murmur, mitral valve prolapse or rheumatic fever?
Do you have a prosthetic or artificial joint?
Have you ever been advised by your doctor to take antibiotics before dental treatment?
Do you have any conditions or therapies that could affect your immune system e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bruise easily or have a bleeding disorder?
Have you ever been hospitalized for any illnesses, operations or x-ray therapy?
Do you have or have you ever had any of the following?
Are there any conditions or disease not listed above that you have or have had?
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
For women only: Are you breast-feeding or pregnant?
What is the reason for today's visit?
How Frequently do you see a dentist?
Are your teeth sensitive to:
Do your gums feel swollen or tender?
Do your have bad breath or a bad taste in your mouth?
Do your jaws crack/pop when you open widely?
Do you grind or clench your teeth?
Do you have food catch between your teeth?
Have you ever had local anesthetic?
Any Complications with local anesthetic?
Have your ever had any problems with previous dental treatment?
Have you ever have any of the following:
Are you satisfied with your teeth?
PATIENT CERTIFICATION OF APPROVAL
I, the undersigned, certify that all of the above Medical and Dental information is true to my knowledge and I have not omitted any pertinent information.
Patient/Parent/Guardian Full Name
I, the undersigned, consent to the performing of the Dental and Oral Surgery Procedures necessary or advisable for me (my children) and accept responsibility for the payment fees.
Patient/Parent/Guardian Full Name
PPATIENT CONSENT FORM: For collection, use and disclosure of personal information
Privacy of your personal information is an important part of our office protocol 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 as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
In this office, Dr. Jelena Bogdanovich, acts as the Privacy Information Officer;
All staff members who come in contact with 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 uses and protection of your information.
Attached to this consent form we have outlined what our office is doing to ensure that:
- Only necessary information is collected about you
- We only share your information with your consent
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
- Our privacy protocols comply with privacy legislation, standards or our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with Dr. Bogdanovich or any member of our staff.
Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
How Our Office Collects, Uses and Discloses Patients' Personal Information
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information:
- To deliver safe and efficient patient care
- To identify and ensure continuous high quality service
- To assess your health needs, and to provide appropriate and needed health care
- To advise you of treatment options
- To enable us to contact you and to establish and maintain communication with you
- To offer and provide treatment in relation to the oral and maxillofacial complex
- To communicate with other healthcare providers such as specialists, physicians and/or laboratories that may assist us during our evaluation and/or treatment phase.
- To communicate with additional providers, such as treating physicians and/or laboratories that may assist us during our evaluation and/or treatment phase
- To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
- To allow us to efficiently follow-up for treatment, care and billing
For teaching and demonstrating purposes on an anonymous basis
- To complete and submit dental claims for third party adjudication and payment
- To comply with legal and regulatory requirements, including the delivery of patients' charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health professions Act
- To comply with agreements entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patient's charts and records to the College for regulatory and monitoring purposes
- To permit potential purchasers, practice brokers or advisors to evaluate the dental practice
- To allow potential purchasers, practice brokers to conduct an audit in preparation for a practice sale
- To deliver your charts and records to the dentists’ insurance carrier to enable the insurance company to assess liability, if any.
- To prepare materials for the Health Professions Appeal and Review Board (HP ARB)
- To invoice for goods and services
- To process credit pard payments and collect unpaid accounts
- To assist this office to comply with all regulatory requirements and the law
By signing the consent-section of the 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 the Regulated Health Professions Act (RHPA) for the purposes of the Royal College or Dental surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense 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 also advise you if such a release in inappropriate.
You may withdraw your consent for the use or disclosure of you personal information, and we will explain the ramifications of that decision and the process.
I, the undersigned: 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 Dr. Bogdanovich has my permission to collect, use and disclose personal information about.
Patient/Parent/Guardian Full Name