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

We require each patient to read and sign our office introduction prior to treatment.

Payment Methods

Our office offers a variety of payment methods for your convenience. In addition to the traditional payments via cash, cheque, debit, 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

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, our office can send a pre-treatment estimate to the insurance company at your request. It is impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. It is your responsibility to have any questions concerning the pre-treatment estimate and/or fees service answered prior to treatment to minimize confusion.

Please be aware that the treatment we recommend is based on your individual needs and never on what your insurance covers. Some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance pays any portion.

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.

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

Patient Communication Preferences

We require each patient to read and sign our patient communication preferences prior to treatment.

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)

Patient Confirmation

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

Language preference

Email address*

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

Home phone

Mobile phone

Business phone

How did you hear about our office?

Reason for today's visit?

Examination
Emergency
Other

If Other please detail

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

Preferred appointment time?

Dental Insurance

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

Subscriber's name

First Last

Date of birth

Group policy holder

First name Last name

Insurance year end

Insurance company

Telephone number

Policy number

Certificate number

Medical Priority

This information will enable us to make any essential contacts.

Family physician

First name Last name

Phone

Who is your medical specialist?

First name Last name

Phone

In case of emergency, please contact

First name Last name

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

Do you have any known allergies?

Yes
No

Allergies

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

If Other please detail

Please select the statements below that apply to you

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

If Other please detail

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

Yes
No

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

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)*

Phone

This field is for validation purposes and should be left unchanged.