Patient Information

First Name:

Last Name:

Nickname/Preferred Name:

Birthdate:

Gender:

Address:

City:

Province:

Postal Code:

Cell Phone:

Other Phone:

Email:

Whom may we thank for referring you to our clinic?

Financially Responsible Party Information

First Name:

Last Name:

Birthdate:

Address:

City:

Province:

Postal Code:

Email:

Cell Phone:

Other Phone:

Relationship to Patient:

Other Financially Responsible Person

First Name:

Last Name:

Birthdate:

Address:

City:

Province:

Postal Code:

Email:

Cell Phone:

Other Phone:

Relationship to Patient:

Dental Insurance Information

Policy Holder's Name:

Policy Holder's Date of Birth:

Relationship to Patient:

Policy Holder's Employer:

Insurance Company Name:

Policy/ID:

Group/Certificate:

Is there a secondary dental insurance plan?

NoYes (If yes, complete information below)

Policy Holder's Name:

Policy Holder's Date of Birth:

Relationship to Patient:

Policy Holder's Employer:

Insurance Company Name:

Policy/ID:

Group/Certificate:

Emergency Contact

Name of Emergency Contact Person:

Relationship to Patient:

Phone:

Dental History

Dentist Name:

Last Dental Visit:

Has the patient had an orthodontic consult or treatment? NoYes If so, when?

Does the Patient need to premedicate prior to dental visit? NoYes

What is the patient's main orthodontic concern?

Please select 'Yes' or 'No' regarding any of the conditions listed below (either now or in the past).

If any of the above dental questions were answered 'Yes', please explain:

Please select 'Yes' or 'No' regarding any of the TMJ conditions listed below (either now or in the past).

If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:

Date of Last Physical:

City:

Province:

Has there been any change in the patient's general health within the last year? NoYes

Is the patient now under the care of a physician (other than routine)? If so, what is being treated? NoYes

Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for? NoYes

Please list any medications currently being taken by the patient (include non-prescription):

List any allergies or sensitivities that the patient may have:

Please select 'Yes' or 'No' regarding any of the condition listed below (eithr now or in the past).

If any of the above medical questions were answered 'Yes' , please explain:

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

Personal Information Protection & Electronic Document Act

Third Party Payer - I hereby authorize Papadopsmiles Orthodontics to release all reasonable and pertinent information contained in my dental records, requested, and required by third party payer, access coverage for treatment and payment of my account.

Signature:

Date:

Referral or Consultation - I understand that my orthodontist may at some time recommend a consultation with another specialist or could need to communicate with my dentist or other professionals, regarding my case. I hereby authorize Papadopsmiles Orthodontics to communicate, discuss and/or share information from my file, with other professionals in a manner he/she feels is necessary.

Signature:

Date:

Privacy Notice And Patient Consent

Our office understands the importance of protecting your personal health information. To help you understand how we are doing that, we have outlined below how our team is collecting, using, and disclosing your information.

We will collect, use, and disclose personal information about you (including personal health information) for the following purposes:

To deliver safe and efficient patient care
To identify and to ensure continuous high-quality service
To assess your health needs
To provide healthcare
To advise you of treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide treatment, care, and services in relationship to the oral and maxillofacial complex, orthodontic care and/or dental care generally
To communicate with other treating healthcare providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
To allow us to maintain communication and contact with you to distribute healthcare 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 applicable dental regulatory college in a timely fashion, when required, according to applicable law
To comply with agreements/undertakings entered voluntarily by a dentist or orthodontist with the applicable dental regulatory college, including the delivery and/or review of patients’ charts and records in a timely fashion for regulatory and monitoring purposes
To deliver your charts and records to the dentist or orthodontist’s insurance carrier, if applicable
To invoice for goods and services
To process credit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
Otherwise with your consent or as permitted or required by law

Your personal information may also be accessed by applicable dental regulatory college as permitted or required by law.

By signing the consent section below, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes listed above. You may withdraw your consent for use or disclosure of your personal information at any time.

Patient Consent

I have reviewed the above information that explains how the office will use my personal information. I hereby authorize the office to collect, use and disclose personal information about me as set out above.

I understand that my personal information will be collected from me or my other health providers or other persons with my consent. My personal information may be disclosed by the office to my health insurer(s) or third-party payer(s) to determine coverage and process payment, and to any other person and for any other purpose with my consent, or as permitted or required by law. I understand that my orthodontist may at some time recommend a consultation with another specialist or could need to communicate with my dentist or other professionals, regarding my case. I hereby authorize the team to communicate, discuss and/or share information from my file with other professionals in a manner that he/she feels is necessary.

The file containing my personal information will be held by the offices or on its servers or those of its service providers. Authorized employees who require it for the purposes of their duties will have access to this file. To the extent provided by applicable law, I may request to have access to and the correction of my personal information.

I also consent to the taking of x-rays, photographs, and other necessary records before, during and after treatment for the purposes of planning, performing, and evaluating treatment.

RESEARCH, PUBLICATION AND DEMONSTRATIONS - By checking this box, I also consent to the use in a way the patient’s identity will not be disclosed of the patient’s x-rays, photographs, and other records before, during and after treatment for the purposes of scientific research, teaching, publication, and demonstration.

MEDIA (PHOTOGRAPHS, VIDEOS) - By checking this box, I consent to the use of x-rays, photographs, and other records before, during and after treatment for the purposes of education, teaching, social media and/or office promotion. My first name may be used but my identity or other personal information will not be shared in any of these instances.

Signature:

Date: