New Patient Form

Personal Contact Information

Name(Required)

First Last

Birthday

Address(Required)

Street Address Address Line 2 City Province Postal Code

Primary Phone Number(Required)

The best number to reach you at.

Alternate Phone Number

Employer

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone Number

Physician Information

Physician's Name

Physician's Phone Number

Pharmacy Information

Pharmacy Name

Pharmacy Phone Number

Dental History

Reason for today's visit

Date of last dental care

Have you had problems with any of the following?

Check all that apply:

Medical History

Date of last physical exam

Health Card #

Do you have dental insurance?

Yes

Insurance Provider

Women, check all that apply

Pregnant

Nursing

Birth control pill

Have you had problems with any of the following?

Are you taking any medications, non-prescription drugs, recreational drugs or herbal supplements of any kind? If yes, please list:

Do you have any allergies or sensitivities to medications, latex/rubber, other? If yes, please list :

Please describe any past hospitalizations, surgeries, impending operations, recent injuries or any other medical conditions the dentist should be aware of:

PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

In this office, Dr. Michael Woo act as the Privacy Information Officers. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. This office will collect, use and disclose information about you for the following purposes:

To provide general dental treatment in relationship to the oral and maxillofacial complex;
To communicate with other treating health care providers, including dental specialists, medical physician, specialists and pharmacist
To allow us to maintain communication and contract with you to distribute health-care information and to book and confirm appointment
To comply with legal and regulatory requirements, including the delivery of patients charts and records to the RCDSO and /or the college of Dental Hygienist of Ontario in a timely fashion, when required, according to the provisions of the REGULATED HEALTH PROFESSIONS ACT OF ONTARIO
To permit potential purchasers, practice brokers or advisors to evaluate the dental practice
To deliver your charts and records or claims to the dentists insurance carrier to enable the insurance company to assess liability and quantify damages or payments
To process credit card payment or to collect unpaid accounts

By signing the consent section of the patient consent form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed.

Patient consent: I have reviewed the above information that explains how your office will use my personal information. I know that your office has a privacy code, and I can ask to see the code at any time. I agree that Dr. Michael Woo and the associates can collect, use and disclose personal information about

(Patient Name Here)

as set out above in the information about the office privacy policies.

Signature

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

Let's get started.