BBSD Patient Intake FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 8Welcome 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 InformationAre you one of our patients? *No, I am a New patientYes, I am a current patient.Name *FirstLastPhone *Best email to contact you? *EmailConfirm EmailDate of BirthHow did you hear about us?Referred by someone I knowWeb search (ex.Google)otherHome Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNextAccount and Insurance InformationAccount InformationThis section is empty as you are one of our patients. Please click Next to proceed. Person responsible for account?SelfOtherPlease provide the name of the insurance policy holder *FirstLastPlease provide the Date of Birth of the insurance policy holder:Do you have dental insurance *YesNoName of Insurance Company *What is the Insurance Plan Number *What is the Insurance Certificate Number? *PreviousNextMedical HistoryPlease select (Yes or No) any of the following that applies to youMedical History Part 1This section is empty as you are one of our patients. Please click Next to proceed. Are you allergic to any Medication? Penicillin or codeine?NoYesPlease the medications you are allergic toHave you ever been advised to take antibiotics prior to dental visit?NoYesDo you have any other allergies? Latex? Food?NoYesHave you ever taken a Bisposphonate medication such as Actonel (Risedronate), Aredia (Pamidronate), Bonefos (Clodronate), Boniva (Ibandronate), Didronel (Etidronate), Fosamax (Alendronate), or Zometa (Zoledronic Acid)?NoYesAre you presently under the care of a doctor?NoYesHave you been a patient in a hospital in the past 2 years?NoYesHave you had general surgery? If so please indicate below when.NoYesPlease indicate the proximal date and type of surgery?Have you ever had a lot of bleeding that needed special treatment?NoYesDo you bruise easily?NoYesDo you have any history of heart trouble? Angina? Heart attack?NoYesDo you smoke, or chew tobacco? If so please indicate the frequency below.NoYesAre you taking oral contraceptives or other hormones?NoYesIf applicable. Are you pregnant? If so please indicate your expected due date?NoYesMedical History DetailsPlease list all medication and non-prescription drugs you are presently taking.PreviousNextMedical HistoryPlease select (Yes or No) any of the following that applies to youMedical History Part 2This section is empty as you are one of our patients. Please click Next to proceed. artificial joint replacementNoYescancerNoYesconfidential heart lesionsNoYesheart murmurNoYeshigh blood pressureNoYesstrokeNoYesglaucomaNoYestuberculosisNoYesarthiritisNoYeskidney troubleNoYesanemiaNoYesjaundiceNoYesasthmaNoYesdiabetesNoYesepilepsyNoYesscarlet or rheumatic feverNoYeshepatitis A / B / CNoYespacemakerNoYesinfective endocarditisNoYesHIVNoYesthyroid troubleNoYesrespiratory problemsNoYesstomach ulcersNoYessinus troubleNoYesdrug/alcohol addictionNoYesnerve disordersNoYeship, knee, TMJ replacementNoYesprosthetic heart valveNoYesbleeding disorderNoYesDo you have any disease, condition or problem not listed that you feel we should know about? Please specify:PreviousNextDental HistoryDental HistoryThis section is empty as you are one of our patients. Please click Next to proceed. 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)?YesNoHave you ever had any type of jaw or facial surgery?NoYesIs there anything that you would change about your smile?NoYesIn case of emergency contact:Name *FirstLastContact Phone number *Relationship *The above medical and dental history is correct and consent for treatment is hereby given.Name *Date / Time *PreviousNextCollection, Use and Disclosure of patient Personal InformationCollection, Use and Disclosure of patient Personal InformationThis section is empty as you are one of our patients. Please click Next to proceed. 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 policyDate / Time *Enter you name as a signature *PreviousNextEMAIL CONTACT CONSENTEMAIL CONTACT CONSENTThis section is empty as you are one of our patients. Please click Next to proceed. 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) *Yes, I consent to receive electronic communication from your officeNo, I do not want to use email to communicate with you.More information about the regulations can be found at: https://www.fightspam.gc.ca/eic/site/030.nsf/eng/homeLast SectionThis 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. PreviousNextPlease click Submit to send us your informationThank 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.EmailSubmit to BBSD