Patient Information Form

Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.

Patient Name:

First
Middle
Last
Preferred Name
Title:
Gender:
Status:
Birth Date: ( DD/MM/YY )
E-mail Address:
Phone:
Home:
Work:
Mobile:
Best time to call:
Address:
City
Province
Postal Code
Whom may we thank for referring you to Metro Dental Care?
Name
Facebook Postcard
MetroDentalCare.ca Newspaper Ad Drive by / Walk in
Other (name below):
   
Please indicate if you have experienced any of the following:
Allergy- Aspirin Allergy- Codeine Allergy- Erythromicin Allergy- Latex
Allergy- Local Anesth Allergy- Penicillin Allergy- Sulfa Anemia
Arthritis Artificial Joints Asthma Birth Control Pill
Blood Disease Cancer Diabetes Dizziness/ Fainting
Emphysema Epilepsy Excessive Bleeding Excessive Bruising
Gastro-Intestinal Concerns Glaucoma Hard to Freeze Hay Fever
Head Injury Hearing Disabled Heart Disease Heart Murmur
Hepatitis A Hepatitis B Hepatitis C HIV+ (AIDS)
High Blood Pressure Hives Jaundice Kidney Disease
Liver Disease Low Blood Pressure Mental Disorders Multiple Sclerosis
Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems
Reumatism Rheumatic Fever Rheumatoid Arthritis Sinus Problems
Skin Rash STD Stomach Problems Stroke
Sleep Apnea Snoring Thyroid Disease TMJ
Tobacco Use Tuberculosis
What medications and vitamins are you currently taking?
What Medications are you allergic to?
Do you require Pre-medication for dental treatment?
WOMEN ONLY:
Are you pregnant? Yes, when is the due date?

Insurance

Primary Policy Holder

Name of Primary Policy Holder

Birthdate of Primary Policy Holder

Name of Insurance Company

Policy/Plan/Group #      Certificate / ID #

Secondary Policy Holder

Name of Secondary Policy Holder

Birthdate of Secondary Policy Holder

Name of Insurance Company

Policy/Plan/Group #      Certificate / ID #

Agreement and Consent for Services:

Metro Dental Care depends on reimbursement from patients and/or their benefits for costs incurred in their care. Our office can file dental claims on your behalf, but are not a party to any insurance programs or contracts. Your dental benefits are a contract between yourself, your employer and your insurance provider. Per the Privacy Act, your plan details will not be released to us, as it is confidential medical information.

For dental services that I have consented to, I will assume responsibility for associated fees. I understand that financial responsibility on the part of each patient must be determined before treatment. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.

I also agree that any images/video taken of me, excluding dental records, x-rays and patient identification photo, may be used in whole or in part for promotional purposes online or in print.

In compliance with Canadian Anti-Spam Laws, you understand that by signing this form, you give us permission to send you information such as appointment reminders, appointment confirmations, news and events.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

I have read the above conditions of treatment and payment and agree to their content

Date: ( DD/MM/YY )

        Other

or

Hours of Operation:

Mon – Thurs: 10am – 7pm
Friday: 10am – 5pm
Saturday: 10am – 5pm