Medical Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.Patient Name* Date of Birth* MM slash DD slash YYYY Email Address* Primary Phone*Cell PhoneWork PhoneHave you moved? Yes No Family Doctor Name Family Doctor Phone Number Pharmacy Name and Location New Address Address Line City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:Name* Relation* Primary Phone*Cell PhoneWork PhoneContact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email I agree to receive emails with related information and updates. Whom may we thank for referring you?* Are any other members of your family patients at our practice? Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment* Insurance Company* Policy/Group #* Certificate/ID #* I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?* Yes No Not Sure/Maybe When was your last medical checkup? (Estimate if necessary)* Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Do you have any allergies?* Yes No Not Sure/Maybe --select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe Please list medications below as well as reactions and approximate dates* Do you have or have you ever had asthma?* Yes No Not Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?* Yes No Not Sure/Maybe Do you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe Please specify*Have you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe Please specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please specify*Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe If yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Are you nervous during dental treatment?* Yes No Not Sure/Maybe Do you use recreational drugs?* Yes No If yes, which drug(s) and how often?Do you consume alcohol?* Yes No If yes, how often and how much?For women only: Are you pregnant or breastfeeding? Pregnant Breastfeeding No When is your delivery date?* MM slash DD slash YYYY How our Office Collects, Uses and Discloses Patient Personal Information Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. By signing the consent section of the patient consent form, you have agreed that you have given your informed consent to the collection, use and or disclosure of the personal information for the purpose that is listed. If a new purpose arises for the use and or disclosure of your personal information, we will seek your approval in advance. Your information may be assessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use of disclosure of your personal information, and we will explain the ramification for that decision, and the process.Patient Consent I have reviewed the above information that explains how your office will use my personal information, and the steps our office is taking to protect my personal information. I know that your office has a privacy code, and I can ask to see the code at any time. I agree that Aylmer Family Dental can collect, use and disclose personal information about myself or my dependents as set out above in the information about the offices privacy policies. I agree to receive emails with related information and updates. SignatureNameThis field is for validation purposes and should be left unchanged.
