INFORMATION QUESTIONNAIRE PID#______________
C O N F I D E N T I A L
Our Privacy Code protects the Personal Information of all our patients.
PLEASE COMPLETE BOTH SIDES OF THIS FORM
Family name:____________________ First Name:_____________Mr/Mrs/Ms/Dr___
Your personal email
Date of birth: Day:______Month:_______Year:_________BusFax:________________
Name of spouse/partner:__________________________________________________
Who referred you to our office?____________________________________________
PERSON RESPONSIBLE FOR ACCOUNT:
If we need to reach you urgently, we should call:_________________________________
Family name:________________________ First Name:________________Mr/Mrs/Ms/Dr____________Home address:__________________________________________________________________________City:________________________Postal Code:__________________Tel:__________________________Employer:___________________________Bus. Tel:_________________________________Date of birth: Day:______Month:_______Year:_________
Please present the details of your dental insurance.
IMPORTANT INFORMATION CONCERNING DENTAL INSURANCE
We do not accept assignment of benefits. You are responsible for payment for services as
they are provided.
We send insurance claims electronically, or provide printed dental claim forms.
Insurance benefit payments go to the policy-holder.
We accept Visa, MasterCard, Interac Debit cards as well as cheques and cash.
INFORMED CONSENT/GENERAL RELEASE
I know that your office has a Privacy Code
, and I can ask to see the Code at any time. I agree that Dr.William
Klein Dentistry Professional Corporation and its professional staff can collect, use, and disclose my personal
information according to the terms of the Privacy Code I have reviewed.
I have provided an accurate and complete Medical and Dental history and have not knowingly omitted anyinformation. I have had the opportunity to ask questions and receive answers regarding this Medical/Dentalhistory and I consent to you contacting my physician, if necessary.
I authorize the provision of diagnostic and treatment services, including the use of local anesthetics asnecessary, and the delegation of such duties that are permitted by Ontario Law. I confirm that I am personallyresponsible for all the fees for diagnosis and treatment charged for me and/or my dependents, whether or not Ireceive insurance benefits. I also authorize the electronic transmission of all dental claims.
Signature of Parent/Guardian:__________________________________________________
Yes Maybe No
Are you in good health at the present time?
Has there been any change in your health in the last year?
Are you being treated by a physician at the present time?
Are you currently taking any of the following medications:
If you ever had an unusual reaction, or allergy to any of the following, please indicate which ones:
Which of the following do you now have, or have you ever had
Yes Maybe No
Do you have risk factors for heart disease or stroke?
Is there anything else we should know about your history?
Copyright: Dr. William Klein Dentistry Professional Corporation, 2010
Peter Satterthwaite Senior Portfolio Manager Capital & Coast District Health Board Private Bag 7902 WELLINGTON To: C&C DHB BOARD Through: Margot Date: May Subject: Resource Allocation & Cardiovascular Resource Allocation EXECUTIVE SUMMARY In October 2002 the Board asked CPHAC (its Community and Public Health Advisory Committee) to begin a program
Targeting tumor cells with Gd(III) chelates through the glutamine transporting system A. Barge1,2, L. Tei2,3, S. Geninatti Crich2,4, R. Stefanìa4, M. Forsterova4, S. Lanzardo2,4, A. Ciampa4, G. Cravotto1, and S. Aime2,4 1Department of Drug Science and Technology, University of Torino, Torino, Italy, Italy, 2CIM - Center for Molecular Imaging, Torino, Italy, 3DISAV, Università del Piemont