New Patient Form

We are committed to excellence in dentistry and appreciate you taking the time to complete this confidential questionnaire. The better we communicate, the better we can care for you. If you have any questions or need assistance, please contact us - we will be happy to help

COVID-19 Pre-Screening Questions

*Required Fields

For the safety of our team, other patients, and yourself, please be truthful and candid in your answers. If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

First Name

Last Name

Have you, your child, or others accompanying you to today’s appointment tested positive for or been diagnosed as having COVID-19 or any other communicable disease? If Yes, when?

Have you, or anyone you have come into contact with, traveled out of the province or out of the country within the last 21 days? If yes, where?

Have you or anyone close to you experienced flu-like symptoms within the past 14 - 21 days such as:

Cough (wet or dry) YesNo

Fever YesNo

Shortness of Breath YesNo

Difficulty Breathing YesNo

Sore Throat YesNo

Muscle/Body Aches YesNo

Nausea/Vomiting/Stomachache YesNo

Fatigue YesNo

Headache YesNo

A Recent Loss of Taste or Smell YesNo

Runny Nose YesNo

Persistent Pain, Pressure, or Tightness in the Chest YesNo

I UNDERSTAND THAT I AM OBLIGATED TO ANSWER THESE QUESTIONS TRUTHFULLY. I ALSO UNDERSTAND IF THE ANSWER TO ANY OF THESE QUESTIONS IS YES, I MAY BE ASKED TO RESCHEDULE TODAY’S DENTAL APPOINTMENT.

New Patient Form

New Patient Information

*Required Fields

Who may we thank for referring you?

About You

Please fill all the details Required

Name

I prefer to be called MaleFemale

Birth Date

Age

Home Address

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Email Address

Employer

Occupation

Dental Insurance Information

Primary Insurance

InsuranceCo Name

Phone

Group/Policy#

Insured's Name

Insured's Birthdate

Relation

ID/Certificate or Employee#

Insured's Employer

Secondary Insurance

InsuranceCo Name

Phone

Group/Policy#

Insured's Name

Insured's Birthdate

Relation

ID/Certificate or Employee#

Insured's Employer

IN CASE OF EMERGENCY, WE SHOULD NOTIFY

Name

Relationship

Day-time Phone #

Phone or Address

Name of Medical Family Doctor

Phone or Address

New Patient Form

New Patient Information

*Required Fields

MEDICAL HISTORY

Name of Physician/and their specialty

Most recent physical examination

Age

What is your estimate of your general health ExcellentGoodFairPoor

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

Drug

Purpose

Drug

Purpose

Drug

Purpose

New Patient Form

New Patient Information

*Required Fields

APPOINTMENT POLICY

When you make an appointment with our office,we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you.In our office policy states that patient must give us 1 business day or 24 hours notice if they cannot keep an appointment.Late notice or missed appointment may be subjected to a minimum $60 charge

FINANCIAL POLICY

Payment in full is due the date of treatment, or on upon start of major treatment.We use Ontario Dental Association fee guide.

Payment Options

1. For your convenience we accept Cash, Debit, Visa, MasterCard.

2. We also offer short term financing options but interest charge will apply.All arrangements may be made in advance and subject to an approval process.

For Patients with Dental Insurance

Dental insurance plans often pay less than actual fee for service.Therefore the patient or Guarantor is responsible party for all the dental service provided.Dental insurance in most cases is a benefit with limitation should not be expected to take care of all costs. YOU ARE ULTIMATELY RESPONSIBLE FOR ALL COST INCURRED REGARDLESS OF WHAT YOUR DENTAL INSURANCE COVERS!

AUTHORIZATION AND CONSENT

General Consent to Treatment

I Agree and consent to a dental examination by Hardik Patel. I Understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done.Also I acknowledge that there are no guarantees,expressed or implied, as to the result of any procedures or dental treatments performed.

Release of Information

I authorize Smiles by Dr. Patel to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Hardik Patel.

I understand and comply with the office Appointment policy.

I understand and comply with the office Financial policy.

I understand and agree to the General consent to treatment.

I authorize the Release of Information.

I authorize the Assignment of Insurance of Benefits.

New Patient Form

COVID-19 Pre-Screening Questions

*Required Fields

Have you or anyone close to you experienced flu-like symptoms within the past 14 - 21 days such as:

I UNDERSTAND THAT I AM OBLIGATED TO ANSWER THESE QUESTIONS TRUTHFULLY. I ALSO UNDERSTAND IF THE ANSWER TO ANY OF THESE QUESTIONS IS YES, I MAY BE ASKED TO RESCHEDULE TODAY’S DENTAL APPOINTMENT.

New Patient Information

About You

Please fill all the details Required

Dental Insurance Information

Primary Insurance

Secondary Insurance

IN CASE OF EMERGENCY, WE SHOULD NOTIFY

MEDICAL HISTORY

DO YOU HAVE OR HAVE YOU EVER HAD

DO YOU HAVE OR HAVE YOU EVER HAD:

ARE YOU:

List all medications, supplements, and or vitamins taken within the last two years

APPOINTMENT POLICY

FINANCIAL POLICY

General Consent to Treatment

Release of Information

I authorize Smiles by Dr. Patel to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Hardik Patel.

I understand and comply with the office Appointment policy.

I understand and agree to the General consent to treatment.

I authorize the Release of Information.

I authorize the Assignment of Insurance of Benefits.

New Patient Form

COVID-19 Pre-Screening Questions

New Patient Form

New Patient Information

About You

Dental Insurance Information

IN CASE OF EMERGENCY, WE SHOULD NOTIFY

New Patient Form

New Patient Information

MEDICAL HISTORY

New Patient Form

New Patient Information

APPOINTMENT POLICY

FINANCIAL POLICY

AUTHORIZATION AND CONSENT