Forms Patient Information (Submit Online, no need to print): First Name Middle Name Last Name Street Address City/Town Postal Code Date of Birth (D/M/Y) Driver’s License # E-Mail Address Home Phone Number Work Phone Number Cell Phone Number Emergency Contact Name Emergency Contact Phone Number How did you find out about Discover Dental? Dental History What is your immediate concern? How would you rate the condition of your mouth? ExcellentGoodFairPoor Are you fearful of dental treatment? YesNo Scale of 1 (none) to 10 (very): Have you ever had an unfavorable dental experience? YesNo Details Have you ever had trouble getting numb or reactions from local an anesthetic? YesNo Did you ever have braces, orthodontic treatment or had your bite adjusted? YesNo Do you /would you have any problem chewing gum? YesNo Do you/would you have any problem chewing bagels or other hard foods? YesNo Have your teeth changed in the last 5 years, become shorter, thinner or worn? YesNo Are your teeth crowding or developing spaces? YesNo Do you have any problems with sleep or wake up with an awareness of your teeth? YesNo Any problems with your jaw joint? (Pain, Sound, Limited opening, Locking, popping) YesNo Do you have tension headaches or sore teeth? YesNo Do you wear or have you ever worn a bite appliance? YesNo Are any teeth sensitive to hot, cold, biting or sweets? YesNo Have you ever been diagnosed or treated for periodontal (gum) disease? YesNo Have you experienced gum recession? YesNo Do your gums bleed when brushing, flossing or eating? YesNo Are your teeth becoming loose? YesNo Have you ever noticed an unpleasant taste or odor in your mouth? YesNo Medical History Name of Physician and their speciality: Date of last medical examination: Purpose: What is your estimate of your general health? ExcellentGoodFairPoor Do you have or have you ever had any of the following: Yes or No Glaucoma YesNo Osteoporosis/Osteopenia (i.e. taking bisphosphonates) YesNo Heart problems YesNo Alcohol/Drug dependency YesNo Heart Murmur YesNo Artificial Prosthesis (i.e. Heart valve or joints) YesNo Rheumatic Fever YesNo Tuberculosis YesNo High Blood Pressure YesNo Breathing or sleeping problems (snoring, sinus) YesNo Low Blood Pressure YesNo Liver Disease YesNo HIV/AIDS YesNo Arthritis YesNo Tumor/Abnormal Growth YesNo Contact Lenses YesNo Radiation Therapy YesNo Head or Neck Injuries YesNo Chemotherapy YesNo Epilepsy, Convulsions (Seizures) YesNo Venereal Disease YesNo Neurologic Problems YesNo Are you taking blood thinners? YesNo Stroke YesNo Hepatitis (type ) YesNo Viral Infections and Cold Sores YesNo Antidepressant Medication YesNo Any Lumps or Swelling in the Mouth YesNo Anemia or Blood Disorder YesNo Hives, Skin Rash, Hay Fever YesNo Emphysema YesNo Kidney Disease YesNo Asthma YesNo Thyroid or Parathyroid Disease YesNo Hormone Deficiency YesNo Jaundice YesNo Diabetes YesNo High Cholesterol YesNo Digestive Disorder (i.e. gastic reflux) YesNo Stomach or Duodenal Ulcer YesNo Are you presently being treated for any other illness? YesNo (FEMALE) Are you taking birth control pills? YesNo Are you subject to frequent headaches? YesNo (FEMALE) Are you pregnant? YesNo Are you a smoker or smoked previously? YesNo Are you allergic or ever had an allergic reaction to: Please list any medication, vitamins, herbal or dietary supplements currently taking and what it is for: Asperin, Ibuprofen, AcetaminophenCodeineLocal AnestheticFluorideMetalsLatexPenicillinErythromycinTetracyclineAny other Medications I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. Signature:______________________________ Date: Discover Dental Dr.Shazia Butt & Associates Financial and Cancellation Policies We are happy to assist you to understand your insurance benefits coverage. However, please know that your insurance policy is an agreement between you, your employer and the insurance company that provides your benefits. Not all services may be covered by your insurance and any fees not covered are the patient’s responsibility. Every insurance plan has its own unique limitations, way of coordinating benefits, exceptions and fee schedules, therefore it is the Patients responsibilities to understand and advise our office of the limits and details of your insurance coverage. We cannot guarantee your individual coverage. All amounts billed for services rendered are ultimately the patient/account holders responsibilities to pay in full. Due to the Privacy Act, insurance companies will not discuss your coverage with dental offices. Please note: There may be a difference in fee guides between our fees and your insurance companies fee guide. You are fully responsible to pay this difference and under no circumstances will we waive this amount. As a courtesy we will direct bill your insurance company, if your plan allows. To do so we require a credit card placed on file. Patient portions are due at the time of service. Any amount not covered by your insurance within 45days becomes your responsibility. We will automatically bill your credit card for any amount under $200 and mail you a receipt. VISA/MC # Expiry/ SVC/CVV: Name on Card: Signature of Card Holder: ______________________________ We do our best to respect our patient’s time and turn we ask the same courtesy. Therefore, our office requires a minimum of 2 business days notice to cancel or change a schedule appointment. If we are not provided with such notice or an appointment is missed, a $50 fee will be charged. This fee must be paid prior to any further appointments. We appreciate your understanding and cooperation with this. Signature:______________________________ Date: Discover Dental – Personal Information Consent Form We are committed to protecting the privacy of our patients’ personal information and utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information, when required by law. We collect information from our patients such as name, home address, work address, contact telephone numbers, e-mail address, birthdays and other government, corporate and/or personal data (collectively referred to as ‘Contact Information’). Contact Information is collected and used for the following purposes: To open and update patient files. To invoice patients for dental services, to process credit cards payments, or to collect unpaid accounts. To process claims for payment or reimbursement from third party health benefit provided and insurance companies. To send reminders and/or phone patients concerning the need for further dental examination or treatment. To send patients information material about our dental practices Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf. Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition and dental treatments (collectively referred to as ‘Medical Information’) Patients Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients’ Medical Information is disclosed: To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf. To other Dentists and Dental Specialists where we are seeking a second opinion and the patient has consented to us obtaining a second opinion. To other Dentists and Dental Specialists if the patient, with their consent, has been referred by us to the other Dentist or Dental Specialist for treatment. To other Dentists and Dental Specialists where those Dentists have asked is, with the consent of the patient, to provide a second opinion. To other Health Care Professionals such as Physicians if the patient, with their consent, has been referred by us to the other Health Care Professional for either a second opinion or treatment. If we are ever considering selling all or part of our Dental Practice, as part of the due diligence process, qualified potential purchasers may be granted access to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest. ** Also effective July 1, 2014 Canada’s Anti Spam Legislation along with existing privacy laws require us to obtain your consent so you can receive / continue to receive email communication from us. I consent to the collection, use and disclosure of my personal information & / or the minor children under my guardianship that attend this practice,_____________ (initials) I consent to receive emails from this office. My Email address will never be given out to anyone other than specialists I approve being referred to._____________ (initials) Printed Patient Name: Email: Dated: Signature of Patient or Guardian: ______________________________
