Creativedentistry.ca

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
PATIENT:
Family name:____________________ First Name:_____________Mr/Mrs/Ms/Dr___
Home address:__________________________________________________________
City:________________________Postal Code:______________Tel:_______________
Your personal email address:____________________________Fax:_______________
Employer:______________________________Occupation:_____________________
Business address:_________________________________Tel:___________________
Date of birth: Day:______Month:_______Year:_________BusFax:________________
Name of spouse/partner:__________________________________________________
Who referred you to our office?____________________________________________
Physician's Name:________________________________Tel:____________________
PERSON RESPONSIBLE FOR ACCOUNT:_____________________ PID#__________
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.
Patient's signature:__________________________________Date:_________________
Signature of Parent/Guardian:__________________________________________________ MEDICAL HISTORY:
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?oHeart murmur Yes Maybe No
sugar?__________________________________________ ____________________________________________ 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

Source: http://www.creativedentistry.ca/PDF%20Articles/Office%20Chart%20Patient%20Registration%20History.pdf