form

Forms

Patient Information (Submit Online, no need to print):

    First Name

    Middle Name

    Last Name

    Street Address

    City/Town

    Postal Code

    Date of Birth (D/M/Y)

    Driver’s License #

    E-Mail Address

    Home Phone Number

    Work Phone Number

    Cell Phone Number

    Emergency Contact Name

    Emergency Contact Phone Number

    How did you find out about Discover Dental?

    Dental History

    What is your immediate concern?

    How would you rate the condition of your mouth? ExcellentGoodFairPoor

    Are you fearful of dental treatment? YesNo

    Scale of 1 (none) to 10 (very):

    Have you ever had an unfavorable dental experience? YesNo

    Details

    Have you ever had trouble getting numb or reactions from local an anesthetic?

    YesNo

    Did you ever have braces, orthodontic treatment or had your bite adjusted?

    YesNo

    Do you /would you have any problem chewing gum?

    YesNo

    Do you/would you have any problem chewing bagels or other hard foods?

    YesNo

    Have your teeth changed in the last 5 years, become shorter, thinner or worn?

    YesNo

    Are your teeth crowding or developing spaces?

    YesNo

    Do you have any problems with sleep or wake up with an awareness of your teeth?

    YesNo

    Any problems with your jaw joint? (Pain, Sound, Limited opening, Locking, popping)

    YesNo

    Do you have tension headaches or sore teeth?

    YesNo

    Do you wear or have you ever worn a bite appliance?

    YesNo

    Are any teeth sensitive to hot, cold, biting or sweets?

    YesNo

    Have you ever been diagnosed or treated for periodontal (gum) disease?

    YesNo

    Have you experienced gum recession?

    YesNo

    Do your gums bleed when brushing, flossing or eating?

    YesNo

    Are your teeth becoming loose?

    YesNo

    Have you ever noticed an unpleasant taste or odor in your mouth?

    YesNo

    Medical History

    Name of Physician and their speciality:

    Date of last medical examination:

    Purpose:

    What is your estimate of your general health? ExcellentGoodFairPoor

    Do you have or have you ever had any of the following: Yes or No

    Glaucoma

    YesNo

    Osteoporosis/Osteopenia (i.e. taking bisphosphonates)

    YesNo

    Heart problems

    YesNo

    Alcohol/Drug dependency

    YesNo

    Heart Murmur

    YesNo

    Artificial Prosthesis (i.e. Heart valve or joints)

    YesNo

    Rheumatic Fever

    YesNo

    Tuberculosis

    YesNo

    High Blood Pressure

    YesNo

    Breathing or sleeping problems (snoring, sinus)

    YesNo

    Low Blood Pressure

    YesNo

    Liver Disease

    YesNo

    HIV/AIDS

    YesNo

    Arthritis

    YesNo

    Tumor/Abnormal Growth

    YesNo

    Contact Lenses

    YesNo

    Radiation Therapy

    YesNo

    Head or Neck Injuries

    YesNo

    Chemotherapy

    YesNo

    Epilepsy, Convulsions (Seizures)

    YesNo

    Venereal Disease

    YesNo

    Neurologic Problems

    YesNo

    Are you taking blood thinners?

    YesNo

    Stroke

    YesNo

    Hepatitis (type )

    YesNo

    Viral Infections and Cold Sores

    YesNo

    Antidepressant Medication

    YesNo

    Any Lumps or Swelling in the Mouth

    YesNo

    Anemia or Blood Disorder

    YesNo

    Hives, Skin Rash, Hay Fever

    YesNo

    Emphysema

    YesNo

    Kidney Disease

    YesNo

    Asthma

    YesNo

    Thyroid or Parathyroid Disease

    YesNo

    Hormone Deficiency

    YesNo

    Jaundice

    YesNo

    Diabetes

    YesNo

    High Cholesterol

    YesNo

    Digestive Disorder (i.e. gastic reflux)

    YesNo

    Stomach or Duodenal Ulcer

    YesNo

    Are you presently being treated for any other illness?

    YesNo

    (FEMALE) Are you taking birth control pills?

    YesNo

    Are you subject to frequent headaches?

    YesNo

    (FEMALE) Are you pregnant?

    YesNo

    Are you a smoker or smoked previously?

    YesNo

     

     

    Are you allergic or ever had an
    allergic reaction to:

    Please list any medication, vitamins, herbal or dietary supplements currently taking and what it is for:

    Asperin, Ibuprofen, AcetaminophenCodeineLocal AnestheticFluorideMetalsLatexPenicillinErythromycinTetracyclineAny other Medications

    I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

    Signature:______________________________

    Date:

    Discover Dental

    Dr.Shazia Butt & Associates

    Financial and Cancellation Policies

    We are happy to assist you to understand your insurance benefits coverage. However, please know that your insurance policy is an agreement between you, your employer and the insurance company that provides your benefits. Not all services may be covered by your insurance and any fees not covered are the patient’s responsibility. Every insurance plan has its own unique limitations, way of coordinating benefits, exceptions and fee schedules, therefore it is the Patients responsibilities to understand and advise our office of the limits and details of your insurance coverage. We cannot guarantee your individual coverage. All amounts billed for services rendered are ultimately the patient/account holders responsibilities to pay in full. Due to the Privacy Act, insurance companies will not discuss your coverage with dental offices.

    Please note: There may be a difference in fee guides between our fees and your insurance companies fee guide.
    You are fully responsible to pay this difference and under no circumstances will we waive this amount.

    As a courtesy we will direct bill your insurance company, if your plan allows. To do so we require a credit card placed on file. Patient portions are due at the time of service. Any amount not covered by your insurance within 45days becomes your responsibility. We will automatically bill your credit card for any amount under $200 and mail you a receipt.

    VISA/MC #

    Expiry/ SVC/CVV:

    Name on Card:

    Signature of Card Holder:

    We do our best to respect our patient’s time and turn we ask the same courtesy. Therefore, our office requires a minimum of 2 business days notice to cancel or change a schedule appointment. If we are not provided with such notice or an appointment is missed, a $50 fee will be charged. This fee must be paid prior to any further appointments. We appreciate your understanding and cooperation with this.

    Signature:
    Date:

    Discover Dental – Personal Information Consent Form

    We are committed to protecting the privacy of our patients’ personal information and utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information, when required by law.

    We collect information from our patients such as name, home address, work address, contact telephone numbers, e-mail address, birthdays and other government, corporate and/or personal data (collectively referred to as ‘Contact Information’). Contact Information is collected and used for the following purposes:

    • To open and update patient files.

    • To invoice patients for dental services, to process credit cards payments, or to collect unpaid accounts.

    • To process claims for payment or reimbursement from third party health benefit provided and insurance companies.

    • To send reminders and/or phone patients concerning the need for further dental examination or treatment.

    • To send patients information material about our dental practices

    Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf.

    Financial information may be collected in order to make arrangements for the payment of dental services.

    We collect information from our patients about their health history, their family health history, physical condition and dental treatments (collectively referred to as ‘Medical Information’) Patients Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

    • Patients’ Medical Information is disclosed:

    • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf.

    • To other Dentists and Dental Specialists where we are seeking a second opinion and the patient has consented to us obtaining a second opinion.

    • To other Dentists and Dental Specialists if the patient, with their consent, has been referred by us to the other Dentist or Dental Specialist for treatment.

    • To other Dentists and Dental Specialists where those Dentists have asked is, with the consent of the patient, to provide a second opinion.

    • To other Health Care Professionals such as Physicians if the patient, with their consent, has been referred by us to the other Health Care Professional for either a second opinion or treatment.

    If we are ever considering selling all or part of our Dental Practice, as part of the due diligence process, qualified potential purchasers may be granted access to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

    ** Also effective July 1, 2014 Canada’s Anti Spam Legislation along with existing privacy laws require us to obtain your consent so you can receive / continue to receive email communication from us.

    I consent to the collection, use and disclosure of my personal information & / or the minor children under my guardianship that attend this practice,_____________ (initials)

    I consent to receive emails from this office. My Email address will never be given out to anyone other than specialists I approve being referred to._____________ (initials)

    Printed Patient Name:

    Email:

    Dated:

    Signature of Patient or Guardian:

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