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Submit Form New Patient Form Patient Information Name * Name First First Last Last Birth date (dd/mm/yyyy) * Email * Address * Street Address Address Line 2 State / Region / Province City Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone * Emergency Contact Emergency Contact Name * Emergency Contact Name First First Last Last Family Doctor Phone * Dropdown Online Friend / Family Member Other We would like to thank who referred you, please list the name of your referral. We would like to thank who referred you, please list the name of your referral. First First Last Last Medical History Are you being treated for any medical condition at the present or have you been treated within the past year? * Yes No If Yes, why? When was your last medical check-up? (dd/mm/yyyy) * Are you taking any medications, non-prescription drugs or herbal supplements of any kind? * Yes No If Yes, please list Has there been any change in you health in the past year? * Yes No If Yes, please explain Do you have any allergic condition? E.g. Asthma, skin rash, medications, latex or rubber gloves, hayfever, hives etc.? * Yes No If Yes, please list Have you ever had a peculiar or adverse reaction to any medication? * Yes No If Yes, please explain Do you have or have you ever had any heart or blood pressure problems? * Yes No Do you have or have you ever had a heart murmur, mitral valve prolapse or rheumatic fever? * Yes No Do you have a prosthetic or artificial joint? * Yes No Have you ever been advised by your doctor to take antibiotics before dental treatment? * Yes No If Yes, please list Do you have any conditions or therapies that could affect your immune system e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? * Yes No If Yes, please explain Have you ever had hepatitis, jaundice or liver disease? * Yes No Do you have a bruise easily or have a bleeding disorder? * Yes No Have you ever been hospitalized for any illnesses, operations or x-ray therapy? * Yes No If Yes, please explain Do you have or have you ever had any of the following? * Chest Pain, Angina Shortness of breath Lung Disease Stomach ulcers Thyroid disease Tuberculosis Arthritis Diet pill therapy Heart attack Prosthetic Heart Valve Cancer Seizures Stroke Pacemaker Diabetes Kidney Disease Drug/Alcohol Dependency No Are there any conditions or disease not listed above that you have or have had? * Yes No If so, what? Do you smoke or chew tobacco products? * Yes No Are you nervous during dental treatment? * Yes No For women only: Are you breast-feeding or pregnant? * Yes No Dental History What is the reason for today’s visit? * Emergency Examination Other If other please explain How Frequently do you see a dentist? * 3-6 Months Annually Other If other please explain When was your last dental visit? (dd/mm/yyyy) * When were your last X-rays? (dd/mm/yyyy) How often do you brush? * How often do you floss? * Do your gums bleed when: * Brushing Flossing Never Are your teeth sensitive to: * Cold Heat Sweets No Do your gums feel swollen or tender? * Yes No Do your have bad breath or a bad taste in your mouth? * Yes No Do your jaws crack/pop when you open widely? * Yes No Do you grind or clench your teeth? * Yes No Do you have food catch between your teeth? * Yes No Have you ever had local anesthetic? * Yes No Any Complications with local anesthetic? Yes No If Yes please explain Have your ever had any problems with previous dental treatment? * Yes No If Yes please explain Have you ever have any of the following: * Bridgework Crowns Dentures Implant Surgery Jaw Surgery Braces Gum surgery Root Canal No Are you satisfied with your teeth? * Yes No If No please explain 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 * Patient/Parent/Guardian Full Name First First Last Last Today’s Date (dd/mm/yyyy) * PATIENT CONSENT 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 * Patient/Parent/Guardian Full Name First First Last Last Today’s Date (dd/mm/yyyy) * 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. PATIENT CONSENT 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 * Patient/Parent/Guardian Full Name First First Last Last Today’s Date (dd/mm/yyyy) * reCAPTCHA If you are human, leave this field blank. Submit Form
