Patient Information Form

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Personal Information







Gender:

Male.Female



















Preferred Method of Contact:

Cell.Home.Work.EmailNo Preference


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CHILDREN ONLY












Child Resides With:

MotherFatherBothOther



Does your child brush/floss their own teeth?

BrushFlossBothNeither



Does your child (please check all that apply):


Breathe through mouthHave a tongue/oral habit/fixationSleep with a bottleSuck thumb or fingersGrind teeth or clench jawHave a strong gag reflexSnoreBite fingernailsHave bad breath often






Insurance Information




















Medical History




Any major illnesses / injuries in the last 3 years?

No.Yes



Please list all current medications, or over-the-counter drugs that you are taking and how often, as well as the conditions they are treating (if applicable)




 


YesNo

Women Only

NoYes
NoYes
NoYes


AsthmaAllergies/Hay FeverLung ProblemsChronic BronchitisCOPDVertigoSinus ProblemsSleep ApneaTuberculosisGlaucomaHeart DiseaseCongenital Heart DisorderHeart MurmurHeart AttackMitral Valve ProlapseStrokeHigh Blood PressureLow Blood PressureHeart SurgeryFainting SpellsRheumatic FeverTachycardiaIrregular Heart BeatProsthetic Heart ValvePace MakerChest Pain/AnginaShortness Of BreathStentDiabetesKidney DiseaseJaundiceThyroid ProblemsStomach UlcersLiver DiseaseHepatitisHeart Burn/Acid ReluxBlood DisorderDrug/Alcohol DependencyEating DisorderAnxiety AttacksCancerAids/HIVMultiple SclerosisFibromyalgiaVenereal DiseaseChronic Fatigue SyndromeSeizures/EpilepsyJoint ReplacementArthritis/RheumatismOrgan TransplantOsteoporosis

Dental Information

NoYes
NoYes
NoYes
NoYes
NoYes

RashDiarrheaFlu/Cold



NoYes


Appointment Policy

We do not charge for cancelled appointments, however we do require 48 hours’ notice to change or cancel an appointment. It is our policy to personally confirm your appointment prior to the appointment date. Should we be unable to reach you directly or leave you a voicemail, please return our call to confirm your appointment, or your appointment will be lost.

 

Personal Information & Financial Consent Policy

Payments for dental services are due at the time of the appointment. Where insurance benefits are ascertainable and assignment allowed, we are pleased to accept payment from the insurance company. I understand that not all fees and/or procedures will be covered by any and/or all dental insurance plans. These amounts, which include, but are not limited to, co-insurance amounts, deductibles, differences in fee guides, limitations on procedures, such as scaling and exams, are the patient’s responsibility and must be paid at the appointment. In many cases we are unable to determine insurance benefits/limitations until we receive insurance proceeds. Patients can always obtain coverage information from their insurance company, and we will always assist in any way possible. I assign dental benefits for claims submitted by Ewart Dental / Macleod Trail Dental and accordingly authorize full payment of all claims to said dental office. Should the insurance company direct payment which I had assigned to the dental office, to me, I undertake to forward the proceeds forthwith to Ewart Dental / Macleod Trail Dental and to not convert the proceeds to any other use. Amounts not paid by the insurance company within 30 days of the service date with be charged back to the patient and payable forthwith. Overdue accounts are charged interest at 2% per month of 24% per year. Accounts which are in default will be referred out for collection purposes and the patient agrees to pay all costs and penalties incurred therein. If upon receipt of insurance proceeds there proves to be a balance unpaid, we require authorization to charge the same to a credit card (our office will call prior to charging your credit card).

 

Personal Information Privacy Policy

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell telephone numbers, and email addresses. (Collectively referred to as “Contact Information”) Contact Information is collected and used for the follow purposes:

  • To open and update patient files
  • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
  • To send reminders to patients concerning the need for further dental examination or treatment
  • To send patients informational material about our dental practice

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 patient’s 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 or all or part of the cost of dental treatment or has asked us to submit a claim on their behalf
  • To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the 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 us, 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 a treatment

If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process 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. I authorize Ewart Dental/Macleod Trail Dental to communicate on behalf of myself and all dependents named on my insurance plan, with my insurance company and/or plan administrator with which I may at any time have coverage. I authorize release of personal/financial/dental/medical Information to the same.

 

Consent

I hereby certify that the medical and dental history is accurate and complete, to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics or any drugs as indicated and I will assume responsibility for all fees associated with those procedures. My signature on this form authorizes submission, including electronic submission and direct assignment, where allowed, for claims for dental services provided. I consent to the collection, use and disclosure of personal information as described herein.

 

I have read and understood the foregoing and agree to the terms and conditions stated herein.