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NEW PATIENT INTAKE FORM

Patient information

Please complete all information to the best of your knowledge. If not applicable, mark it as N/A.

Questions marked with a* are required. Questions you are unsure of or would prefer to answer verbally can be skipped.

Patient Name*

First Last

Preferred Name / Nickname

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of birth*

Home Phone*

Mobile Phone*

Email

Emergency contact name

First Last

Phone

Email

Relationship

Do you have dental insurance?*

Yes

No

Insurance information

Primary insurer

Insurance company

Certificate/ID number

Group/Policy number

Are you a dependant?

Yes

No

Name of insurer

First Last

Insurer date of birth

Relationship

Secondary insurer

Insurance company

Certificate/ID number

Group / policy number

Are you a dependant?

Yes

No

Name of insurer

First Last

Insurer date of birth

Relationship

Canadian Dental Care Program (CDCP)

Member ID

Coverage start date

As per welcome package.

How did you hear about our clinic?

NEW PATIENT INTAKE FORM

Consent

I consent to have treatment by my denturist at Ottawa Valley Denture Clinic (OVDC).

I consent to have my dentist or physician contacted if additional dental/medical information is required for my dental care.

I understand that this clinic does not accept assignment of benefits, and OVDC will not submit to or claim from insurance companies. Any claim forms will be printed off and provided to the patient at the completion of service.

I assume responsibility for all fees incurred. All fees not covered by my insurance company is my responsibility.

We understand that circumstances change and we ask to be notified at least 24 hours in advance. This allows us to manage our schedule effectively and offer the time slot to another patient in need. Failing to show up for your scheduled appointment without prior notice will result in a fee of $75. We appreciate your understanding and cooperation in ensuring we can provide timely and efficient care to yourself and all our patients. Please note we consider exceptions for unavoidable emergencies on a case-by-case basis.

Patient Authorization and Sharing of Information

Many of our patients choose to have family members, such as spouses, significant others, parents, or children, contact us to inquire about treatment plans, procedure codes, and financial information.

Additionally, family members and caregivers may assist with booking, rescheduling, or canceling appointments. However, in compliance with the Personal Health Information Protection Act (PHIPA), we are unable to share this information with anyone without your explicit consent. If you would like to grant access to family members or caregivers for these purposes, please complete and sign this form.

You have the right to revoke this consent in writing, except where we have already made disclosures based on your prior consent.

I hereby authorize Ottawa Valley Denture Clinic (OVDC) to share my information and communicate with the following individuals regardin

If someone other than yourself will be contacting the office for appointment scheduling, treatment inquiries, payments, insurance matters, or other related issues, please list all individuals who are authorized to receive information or communicate on your behalf (e.g., Spouse, Son/Daughter, Caregiver, etc.)

Name

Relationship to patient

To ensure that we can confirm your appointments and provide important updates regarding your appointments, treatment plan, or care, our office may need to leave messages. If we are unable to reachyou directly by phone, please indicate your preferences below:

Messages may be left with:

Name of person filling out this form

First Last

Signature*

NEW PATIENT INTAKE FORM

Patient information

Insurance information

Primary insurer

Secondary insurer

Canadian Dental Care Program (CDCP)

NEW PATIENT INTAKE FORM

Medical history

NEW PATIENT INTAKE FORM

Dental History

Denture History

NEW PATIENT INTAKE FORM

Consent

Patient Authorization and Sharing of Information