Patient Intake Information

Welcome to Our Dental Office

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

Office Introduction

Payment Methods

Our office offers a variety of payment methods for your convenience. In addition to the traditional payments via cash, check, MasterCard, VISA, EFT and online bill payments, we have financing options available through Dental Card Financing. Our goal is to help you secure the treatment you need while providing options that fit your budget. If you have questions, please ask one of our front desk team members to explain your options.

Insurance

Our front desk team is well trained and knowledgeable in third party payment issues. As a service to our patients, we are happy to file your dental insurance claims electronically for you. We will accept insurance benefits provided all paperwork and necessary information is complete. We do require that deductibles and co-payments be paid at the time of service. Your insurance policy is a contract between you, your employer and the insurance company, not the dental office. Any fees not covered by your insurer will be your responsibility and an estimate of your portion is the amount expected at the time of service. All balances are due upon receipt.

Appointments

We would like to convey to you the importance of your scheduled appointment time. Our appointment times are specifically reserved for each patient. We require the courtesy of 2 business days advance notice by phone should you need to cancel or change your appointment. This courtesy allows us to give your appointment time to patients who may be waiting.

Patients who fail to arrive for their appointed time or who do not provide required advance notice will be subject to a $50 fee.
We request that you call during office hours to reschedule or cancel appointments. Please do not leave messages to cancel appointments as our system does not recognize this as a cancellation and you will be subject to a $50 fee.

Consent*

I have read and understand the office policy and agree to comply with it.

Patient Communication Preferences

Communication Methods (Select all that apply)*

Our office offers a variety of ways to stay connected to our office. You may select more than one option that suits your lifestyle best:

Call me at home
Call me via cell phone
Text me via cell phone
Contact me at work
Contact me via email

Promotion Communication Preferences*

Our office provides various patient appreciation events throughout the year and we often host various promotions and like keeping our patients informed about the various activities we get ourselves involved in as well as events we would like to involve you in. Please let us know your promotional communication preferences

Please include me on your mailing list.
Please DO NOT include me on your mailing list (NOTE: this excludes any direct mail that comes you via Canada Post. We mail out based on postal code and cannot individually select which home it goes to)

Consent*

I have read and understand the patient communication preferences and agree to give Yazdani Family Dentistry permission to communicate with me via my selection preference.

Registration Information

This information will enable us to maintain communication with you

Patient name*

First Last

Date of birth*

The patient is a/an*

Adult
Child
Adult under guardianship

Name of guardian

First Last

Relationship to patient

How did you hear about us?

Search engine (Google, yahoo, etc.)
Recommended by friend or family
Social media
Advertisement (direct mail, newspaper, radio, etc.)
Other

Name or referral source

Language preference

English

Email address*

Email Newsletters / Announcements

I consent to receiving, at most, 3-4 emails per month inviting me to patient appreciation events, other events and promotions.

Address*

Street Address Suite / P.O. Box City State / Province / Region ZIP / Postal Code Country

Home phone

Business phone

Reason for today's visit?

Examination
Emergency
Other

Reason for today's visit

Is there a dental problem you would like to be treated immediately?

Preferred appointment time

Select All
Morning
Afternoon
Evening

Dental Insurance

Patients with ODSP or Ontario Works benefits, please call our office for more information about your coverage.

Subscriber's name

First Last

Subscriber's date of birth

Subscriber's phone

Group policy holder

First Last

Insurance year end

Insurance company

Policy number

Certificate number

Medical Priority

This information will enable us to make any essential contacts.

Family physician

First Last

Physician's phone

Medical specialist

First Last

Specialist's phone

Emergency contact

First Last

Emergency contact phone

Medical History

When was your last visit to a Physician?

When was your last complete physical examination?

List any prescription or non-prescription drugs, including herbal remedies that you have recently, or are presently, taking

Name of drug	Dosage

Click the + to add additional lines

Have you ever reacted adversely to any of the following medications or injections? (Select all that apply)

Penicillin or other antibiotics
Aspirin
Codeine
Local anesthetic
Nitrous Oxide
Latex
Other medications

Other medication or injections with adverse reactions

Please select the statements below that apply to you

I have been treated for a medical condition within the last two years
I have been hospitalized in the past
I have previously been advised against taking a specific type of medication
I smoke or use another form of tobacco
I wear a transdermal nicotine patch
I am alcohol and / or drug dependent
I smoke Marijuana
I am receiving treatment (Regarding the above)
I am taking blood thinners

Indicate which of the following you presently have or have ever had (Select all that apply)

Other conditions

Sleep Disorder Questionnaire

Do you snore loudly?

Yes
No

Do you often feel tired, fatigued or sleepy during the day time?

Yes
No

Do you have or are being treated for high blood pressure?

Yes
No

Do you have a BMI over 35? (weight in kg, divide by height in meters, then divide again by height in meters)

Yes
No

Neck circumference >16 inches?

Yes
No

Are you male?

Yes
No

General Release*

I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other health information I have provided, I will advise this dental office. I authorise the dentist to preform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I takes responsibility for fees associated with these services.

Signature (of Patient / Parent / Guardian)*

For Office use only

Are you the type of person who likes a lot of detailed information, or do you prefer more bottom line information?

In order for us to provide you with exceptional quality of care, we would like to get to know you better. As providers, all of the following are important to us. However, we would like to know which is the most important to you:

Please circle which of these you value the most in terms of your teeth and any treatment that is rendered

Cosmetic: Meaning you are happy with the appearance of your smile
Function: Meaning you value the ability to eat and speak well
Comfort: Meaning you value being at ease during your visit
Longevity: Meaning your priority today is keeping your teeth for a lifetime

What is the most important quality for you in a relationship with a Doctor?

Please circle which of these are barriers to moving forward with proposed treatment (ideal treatment)

Fear
Time
Budget
No trust