New Patients - Guelph, Kitchener, Listowel, Minto, Stratford

Patient Information

*Name:

*Date of Birth

*Gender

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Male

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Female

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Not Listed

*Street Address:

*City:

*Province

*Postal Code:

*Primary Phone Number:

*Primary Phone Location:

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Home

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Cell

Secondary Phone Number:

Secondary Phone Location:

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Home

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Cell

Work Phone Number:

*Email

Employer:

*Emergency Contact Name:

*Emergency Contact Phone Number:

Physician's Name:

Physician's Phone Number

Pharmacy Name:

Pharmacy Phone Number

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

*Signature of Patient / Legal Guardian:

*Print Name

*Todays Date

NEW PATIENT REGISTRATION FORM

Patient Information

Dental History

Check the boxes if you have had problems with any of the following:

Medical History

Check if you have had problems with any of the following:

Dentist's Initials:

Patient Consent Form

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION