First Name

Last Name

Status

Single

Married

Child

Other

Date of Birth

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Work Tel

Home Tel

Physician

Previous Dentist

Why have you decided to change dental offices?

How did you hear about us?

Name of insured if different from above:

Employer

Date of Birth of Insured

Insurance Company

Policy/Group

Division (If applicable):

Certificate ID#:

Division (If applicable):

Do you have Secondary Insurance?

Yes

Name

Relationship:

Tel

Clenching or grinding your teeth while awake or asleep?

Yes

Biting your cheeks or lips?

Yes

Mouth breathing while awake or asleep?

Yes

Placing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)?

Yes

I UNDERSTAND that in order to get my examination

You will be asked about medical history, dental history, current and previous, Chief complaint, goals of the treatments. You will disclose the current accurate information to the best of your knowledge.
All information you share is confidential, only necessary information is collected about you.
I only share your information with your consent.
Storage, retention and destruction of your personal information complies with existing legislation, and privacy.
Privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons.
Extra oral exam, Intra oral exam, elective Oral cancer screening, TMJ assessment, Dental Occlusion Assessment, Specific Exam, or Second opinion are all procedures that need the use of sterilized dental instruments that will be used during the exam. You have the right to deny use of any instruments. You have the right to ask all the questions about different procedures and getting them explained to you before they are conducted.
Collecting additional information such as, dental casts or impressions, x-ray or other means of imaging, photography, Referral to other specialists such as and not limited to: Periodontists, Endodontists, Orthodontists, Oral medicine, Oral anaesthesia, Maxillofacial Surgeon and Physician is needed to formulate accurate diagnoses and you will be informed about them as needed. You have the right to deny any of those data collections procedures.
You authorize photos, slides, and x-rays of my care and treatment during or after its completion to be used for the advancement of dentistry and for reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.

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