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Patient Information

Name:

Address: Apt#: Unit#:

City: Postal Code:

Home Phone: Business Phone: Ext:

Mobile: Email:

Date of Birth: Gender:

Health Card#: Version Code:

Next of Kin / Closest Relative: Relationship:

Home Tel #: Work Tel #: Mobile Tel #:

Referral Information

Referred by: DentistDoctorSpecialistOther

Referring Name: Phone:

Regular Dentist: Phone:

Family Doctor: Phone:

Insurance Information

Dental Insurance: YesNoDual

Covered by Ontario Government Program?: YesNo

Medical History Questionnaire

1. Are you currently being treated for any medical condition or have you been treated within the past year? YesNoNot Sure

If yes, please explain:

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year? YesNoNot Sure

If yes, please explain:

4. Are you taking any medications, non‑prescription drugs or herbal supplements of any kind? YesNoNot Sure

If yes, please list them:

5. Do you have any allergies? YesNoNot Sure

If yes, please list them using the categories below:

a) Medications:

b) Latex/rubber products:

c) Other (e.g. seasonal/environmental, foods):

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? YesNoNot Sure

If yes, please explain:

7. Do you have or have you ever had asthma? YesNoNot Sure

8. Do you have or have you ever had any heart or blood pressure problems? YesNoNot Sure

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (infective endocarditis), a heart condition from birth (congenital heart disease) or a heart transplant? YesNoNot Sure

10. Do you have a prosthetic or artificial joint? YesNoNot Sure

11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? YesNoNot Sure

12. Have you ever had hepatitis, jaundice or liver disease? YesNoNot Sure

13. Do you have a bleeding problem or bleeding disorder? YesNoNot Sure

14. Have you ever been hospitalized for any illnesses or operations? YesNoNot Sure

If yes, please explain:

15. Please check any of the following conditions you have or have had:

Chest pain/AnginaRheumatic feverPacemakerSteroid therapySeizures (epilepsy)Heart attackLung diseaseDiabetesMitral valve prolapseKidney diseaseStroke/TIATuberculosisStomach ulcersThyroid diseaseShortness of breathHeart murmurCancerArthritisDrug/Alcohol/Cannabis use or dependencyOsteoporosis (e.g. Fosamax, Actonel)

16. Are there any conditions or diseases not listed above that you have or have had? YesNoNot Sure

If yes, please explain:

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? YesNoNot Sure

If yes, please explain:

18. Do you smoke or chew tobacco products? YesNoNot Sure

19. Are you nervous during dental treatment? YesNoNot Sure

20. Are you breastfeeding or pregnant? YesNoNot Sure

If pregnant, what is the expected delivery date?

21. Do you identify as a patient with a disability? YesNoNot Sure

If yes, please explain:

To the best of my knowledge the above information is correct.

Patient/Parent/Guardian Signature:

Date:

Privacy Consent

I have reviewed the information about how your office will collect, use and disclose my personal information. I agree that Spectrum Oral Surgery can collect, use and disclose personal information about (patient’s name) as set out above. [acceptance* privacy-consent use_label_element] I Agree

Patient’s Name:

Patient/Parent/Guardian Signature:

Print name: Date:

Signature of Witness:

Financial Policy

Please read the financial policy above carefully and select the appropriate agreement:

Financial Agreement for Insured PatientsFinancial Agreement for Non-Insured PatientsFinancial Agreement for Government Assisted Plans

Person responsible for account:

Relationship to the patient:

Signature:

Date:

CDAnet Insurance Information

Primary Insurance Information

Name of patient:

Name of policy holder:

Policy holder’s date of birth:

Insurance company:

Policy/Group #:

Subscriber ID/Certificate #:

Relationship of patient to policy holder: DependentSpouse

Secondary Insurance Information

Name of policy holder:

Policy holder’s date of birth:

Insurance company:

Policy/Group #:

Subscriber ID/Certificate #:

Relationship of patient to policy holder: DependentSpouse

Do you have triple coverage? YesNo

I authorize release to my dental benefits plan administrator of the information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of service described to the named oral surgeon. [acceptance* cd-authorization use_label_element] I Agree

Signature of patient, parent or guardian:

Date: