Health History & Registration

Feel free to contact us if you have any questions

PATIENT INFORMATION

PATIENT INFORMATION

First Name *

Middle Initial

Last Name *

Sex *

Male

Female

Age *

Date of Birth *

Email *

Address *

City / Town *

Province *SelectOntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland & Labrador

Postal Code *

Phone Number *

Employer / Occupation

Who May We Thank for Referring You to Our Office?

Title for Guardian

If Patient is a Minor PLEASE FILL OUT PORTION BELOW

PARENT OR GUARDIAN INFORMATION

PARENT OR GUARDIAN INFORMATION

Full Name

Relationship

Address

City / Town

ProvinceSelectOntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland & Labrador

Postal Code

Phone Number

Email

DENTAL INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION (Primary Carrier)

Insured's Name

Insurance Company

Employer Name

Certificate / Member ID#

Group / Plan #

EMERGENCY INFORMATION

EMERGENCY INFORMATION

Full Name *

Relationship

Phone Number *

Title for Right Column

It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

DENTAL HISTORY

DENTAL HISTORY

How long since you have seen a dentist? *

Last complete dental exam date: *

Last full mouth x-rays date: *

Are you having problems now? *

Yes

No

Ia your present dental health POOR? *

Yes

No

Are you unhappy with your dentures?

Yes

No

Would you like to know more about Permanent Replacement?

Yes

No

Are you apprehensive about dental treatment? *

Yes

No

Do you have periodontal (gum) treatments? *

Yes

No

Do your gums bleed or feel tender or irritated? *

Yes

No

Are your teeth sensitive to: *SelectHotColdSweetsPressureNone of the above

Are you unhappy with the appearance of your teeth? *

Yes

No

Are you grinding or clenching your teeth? *

Yes

No

Do you have headaches, ear aches, or neck pain? *

Yes

No

Have you worn braces on your teeth? *

Yes

No

Do you have discoloured teeth that bother you? *

Yes

No

Would you like to look better or different? *

Yes

No

Do you regularly use dental floss? *

Yes

No

Name of previous Dentist

City / Town *

Province *SelectOntarioQuebecNova ScotiaNew BrunswickManitobaBritish ColumbiaPrince Edward IslandSaskatchewanAlbertaNewfoundland & Labrador

MEDICAL HISTORY

MEDICAL HISTORY

Do you have any current health problems? *

Yes

No

Are you under physicians care now? *

Yes

No

For what?

What medications are you taking?

Are you pregnant? *

Yes

No

Do you use smoke? *

No

Cigar

Cigarette

Pipe

Chewing Tobacco

Title

Please select any of the following which you have had or presently have:

Disorders *SelectAids / HIVAnaphylaxisAnemiaArthritisArtificial Heart ValvesArtificial JointsAsthmaAtopicBack ProblemsBlood DiseaseCancerChemical DependancyChemotherapyCirculatory ProblemsCortisone TreatmentsCough (persistent)Cough up BloodDiabetesEpilepsyFaintingFood AllergiesGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHerpesHepatitisHigh blood pressureJaw PainKidney disease or MalfunctionLiver DiseaseMaterial AllergiesMitral valve prolapsePacemaker/ Heart SurgeryPsychiatric CareRapid Weight Gain/ LossRadiation TreatmentRespiratory DiseaseRheumatic/ Scarlet FeverShinglesShortness of breathSkin rashSpine BifidaStrokeSurgical ImplantSwelling of the feet or anklesThyroid disease or MalfunctionTobacco HabitTonsillitisUlcer/ ColitisVenereal DiseaseNone of the above

Title

Are you allergic to or have you reacted adversely yo any of the following medications?

Medications *SelectAspirinNitrous OxideLocal AnaestheticCodeineErythromycinPenicillinLatex (balloons, gloves, etc)None of the above

Are you allergic to any other medications or substances. If yes lease list.

COVID-19

COVID-19

1. Are you experiencing any of the following symptoms? Select all that apply: *SelectSevere difficulty breathing(struggling for each breath, can only speak in single words)Severe chest pain(constant tightness or crushing sensation)Feeling confused(for example, unsure of where you are)Losing ConsciousnessNone of the above

2. Are you experiencing any of the following symptoms? Select all that apply: *Selectfever. (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)chillsbarking cough, making a squeaky or whistling noise when breathing. (croup)shortness of breath. (out of breath, unable to breathe deeply)sore throatdifficulty swallowinghoarse voice. (more rough or harsh than normal)DiarrheaAbdominal painPink eye (conjunctivitis)runny nosestuffy or congested noselost sense of taste or smellheadachedigestive issues. (nausea/vomiting, diarrhea, stomach pain)fatigue (lack of energy, extreme tiredness)falling down more than usualfor young children and infants: sluggishness or lack of appetiteNone of the above

3. Do any of the following apply to you? *SelectI am 65 years old or olderI have a condition that affects my immune system(for example, HIV/AIDS, lupus, other autoimmune disorder)I have a chronic health condition(for example, diabetes, emphysema, asthma, heart condition)I am getting treatment that affects my immune system(for example, chemotherapy, corticosteroids, TNF inhibitors)None of the above

4. If you are the age of 65 years of age or older, are you experiencing any of the following symptoms; delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes

No

5. Have you travelled outside of Canada in the last 14 days? *

Yes

No

6. Has someone you are in close contact with tested positive for COVID-19? (
For example, someone in your household or workplace.) *

Yes

No

7. Are you in close contact with a person who either: *Selectis sick with new respiratory symptoms?recently traveled outside of Canada?None of the above

Security Code *

Security code is not correct

Financial Policy

We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. If you have questions , please discuss them with our financial team members.

Erindale Village Dental is pleased to offer you the following payment options.

Option 1: 

Payment is due in full the day treatment is rendered. We accept cash, certified cheques, debit, Visa, and MasterCard. 

Option 2: 

Your insurance company may require you to, or you may prefer to, pay for your dental work directly on your treatment day, and have your insurance company reimburse you. Erindale Village Dental will process your payment on the date treatment was rendered. Our team members will assist you in submitting the necessary documents to your insurance carrier.

Option 3:

You may leave your credit card number on file (secure database) and we will directly bill your insurance company, you don't have to wait around on your treatment day. Once your insurance company has paid us their portion, our Financial Advisors will process your patient portion to the credit card on file. Erindale Village Dental can provide estimates when requested. Receipts can be mailed or emailed to you.

Appointment Policy

Personal Data Protection

Dental records are collections of sensitive personal patient information compiled to allow dentists and other dental health care providers to offer dental treatment, maximize continuity of care, and maintain optimal standards of care. Original dental records compiled by a dentist are the legal property of the dentist.

Patients have a legal right to examine and copy their records and to control the use and dissemination of the information contained in their records. Dentists require patients to provide complete , accurate and intimate health details in order to provide safe and effective treatment. Therefore , owners hip of original dental records obligates the security and confidentiality of the information contained therein, which may be developed only with the permission of the patient except when otherwise required by law.

Patients have the right to control the disclosure of their dental records to others. Release of information must be informed ; must be specific and for a one-time event; must afford the patient an opportunity to review the information being requested and released prior to its transfer, and with the opportunity to withdraw prior consent; must not be used for any purpose other than the primary and specific use requested ; and must be done with the patient 's permission, preferably in writing.

Patients are entitled to receive dental care in a confidential selling free of third party intrusion . Release of patient information to third parties must adhere to the basic principles of confidentiality and patient rights outlined above with the intention of enabling patients to review any and all third-party benefits to which they may be entitled. Patients may be unaware of the information that third parties may have access to under broad-ba sed consents to release dental records , and the scope of this information may exceed the needs of a third party to determine benefits. It becomes the responsibility of the dentist and other dental health care providers to protect the confidentiality and privacy of their patients.

Where a third party (e.g., government agency, Canada Revenue Agency, dental association or insurance company) has received patient permission to use information from the patient's dental records for financial audits, all patient identity and unrelated information (e.g., health history, personal information) shall first be removed from the records. No third party can demand access to patient dental records (including financial records) except with specific patient consent in writing by legal statute or by court order.