Patient Forms

Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general

Private & Confidential Health History and Personal Information

Are you one of our patients? *

Name *

First

Last

Phone *

Best email to contact you? *

Email

Confirm Email

Date of Birth

Home Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Account and Insurance Information

Person responsible for account?

Please provide the name of the insurance policy holder *

First

Last

Please provide the Date of Birth of the insurance policy holder:

Do you have dental insurance *

Name of Insurance Company *

What is the Insurance Plan Number *

What is the Insurance Certificate Number? *

Medical History

Please select (Yes or No) any of the following that applies to you

Are you allergic to any Medication? Penicillin or codeine?

Have you ever been advised to take antibiotics prior to dental visit?

Do you have any other allergies? Latex? Food?

Have you ever taken a Bisposphonate medication such as Actonel (Risedronate), Aredia (Pamidronate), Bonefos (Clodronate), Boniva (Ibandronate), Didronel (Etidronate), Fosamax (Alendronate), or Zometa (Zoledronic Acid)?

Are you presently under the care of a doctor?

Have you been a patient in a hospital in the past 2 years?

Have you had general surgery? If so please indicate below when.

Have you ever had a lot of bleeding that needed special treatment?

Do you bruise easily?

Do you have any history of heart trouble? Angina? Heart attack?

Do you smoke, or chew tobacco? If so please indicate the frequency below.

Are you taking oral contraceptives or other hormones?

If applicable. Are you pregnant? If so please indicate your expected due date?

Medical History Details

Please list all medication and non-prescription drugs you are presently taking.

Medical History

Please select (Yes or No) any of the following that applies to you

artificial joint replacement

cancer

confidential heart lesions

heart murmur

high blood pressure

stroke

glaucoma

tuberculosis

arthiritis

kidney trouble

anemia

jaundice

asthma

diabetes

epilepsy

scarlet or rheumatic fever

hepatitis A / B / C

pacemaker

infective endocarditis

HIV

thyroid trouble

respiratory problems

stomach ulcers

sinus trouble

drug/alcohol addiction

nerve disorders

hip, knee, TMJ replacement

prosthetic heart valve

bleeding disorder

Do you have any disease, condition or problem not listed that you feel we should know about? Please specify:

Dental History

When was the last time you saw a dentist? *

How often do you brush and floss your teeth?

Have you ever had a bad experience at the dentist?

Have you ever had local anesthetic (freezing)?

Have you ever had any type of jaw or facial surgery?

Is there anything that you would change about your smile?

In case of emergency contact:

Name *

First

Last

Contact Phone number *

Relationship *

The above medical and dental history is correct and consent for treatment is hereby given.

Name *

Date / Time *

Collection, Use and Disclosure of patient Personal Information

Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general health.

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

This office will collect, use and disclose your personal information for the following purposes:

To establish and maintain communication with you
To offer and provide treatment, care and service in relation to the oral and maxillofacial complex and dental care generally
To communicate with other treating health-care providers, including a specialist general dentist who are the refereeing dentists and or peripheral dentists
To allow us to maintain communication and contact with you to distribute the care information and to book and confirm appointments
To allow us to efficiently follow up for treatment, care and billing
For teaching and demonstrating purpose on an anonymous basis
To complete and submit dental claims for third party adjudication and payments
To comply with legal and regulatory requirements, including the delivery of patient charts and records to the Royal College of Dental Surgeons of Ontario (RCDSO) in a timely fashion, when required, according to the provisions of the Regulated Health Professional Act (RHPA)
To comply with agreement/undertakings entered voluntarily by the members with RCDSO, including delivery and/or review of patient charts and records to the RCDSO in a timely fashion for regulatory and monitoring purposes.
To permit potential purchases, practice brokers or advisors to evaluate the dental practice
To process credit card payments
To collect unpaid accounts
To assist this office to comply with all regulatory requirements
To comply generally with the law

By Signing the below consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purpose that are listed. If a new purpose arises for the use and/or disclosure of your personal information we will seek your approval in advance.

I have reviewed the above-mentioned information that explains how your office will use my personal information, and the steps your office is taking to protect my information

I acknowledged that your office has a copy of the privacy act and I can see it at any time

I agree that Dr. Irina Smirnova can collect, use and disclose personal information about me and described on our collection, use and disclosure of the patient’s personal information policy and the patient consent form.

Collection, Use and Disclosure of patient Personal Information *

Yes, I have read and agreed that Dr. Irina Smirnova can collect, use and disclose personal information about me and described on our collection, use and disclosure of the patient’s personal information policy and the patient consent form.
No, I do not agree with the terms and conditions of the Patient's Personal Information policy

Date / Time *

Enter you name as a signature *

EMAIL CONTACT CONSENT

To comply with Canada's anti-spam law, we want to confirm that you would like to contine receiving our emails. We mostly use email to send our appointment reminders and reply to patients' request to change or book appointments. Please select (Yes or No) *

More information about the regulations can be found at: https://www.fightspam.gc.ca/eic/site/030.nsf/eng/home

COVID-19 Screening Question

We are required by our Regulating body to screen you for COVID-19. Please answer the following to the best of your knowledge.

Q1: Did you receive your final (or second) vaccination dose more than 14 days ago? *

Yes
No

Q2: Do you have any of the following symptoms?

Fever and/or chills? *

Yes
No

New onset of cough or worsening chronic cough ? *

Yes
No

Shortness of breath ? *

Yes
No

Decrease or loss of sense of taste or smell? *

Yes
No

If adult >18 years of age: unexplained fatigue/lethargy malaise muscle aches(myalgias)? *

Yes
No

If child <18 years of age: nausea/ vomiting, diarrhea? *

Yes
No

Q3: Have you tested positive for COVID-19 in the past 10 days or have they been told they should be isolating? *

Yes
No

Q4: Did you travel outside of Canada in the past 14 days? *

Yes
No

Q5: Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes
No

Are you over the age of 60? *

Yes
No

This is the last section. Note that you will not be able to go back after clicking [Next]. Please ensure that the information you provided is accurate to the best of your knowledge.

Please click Submit to send us your information

Thank you for taking the time to complete this form prior to your appointment. The welfare of our patients and our staff is of the utmost importance to us your cooperation is helping us address the health needs during these challenging times.

Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general

Private & Confidential Health History and Personal Information

Account and Insurance Information

Account Information

Medical History

Medical History Part 1

Medical History

Medical History Part 2

Dental History

Dental History

In case of emergency contact:

The above medical and dental history is correct and consent for treatment is hereby given.

Collection, Use and Disclosure of patient Personal Information

Collection, Use and Disclosure of patient Personal Information

EMAIL CONTACT CONSENT

EMAIL CONTACT CONSENT

COVID-19 Screening Question

Q2: Do you have any of the following symptoms?

Please click Submit to send us your information