Client Care

Patient Medical Information | Dental Hygiene of Niagara

Title:

Full Name:

Date of Birth:

Occupation:

Employer:

Email:

Address:

City:

Postal Code:

Phone Number:

Phone Type:

Mobile Home

Referred by:

Emergency Contact Name:

Emergency Contact Phone:

If this information I have given above is true to the best of your knowledge, please type your full name below:

Full name:

Today's date:

I agree that this information that I have provided above is true to the best of my knowledge.

I agree

Patient Consent Form For Collection, Use And Disclosure Of Personal Information

Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed in collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. Please do not hesitate to discuss our policies with any individual on our dental team and be assured that we are committed to ensuring that you receive the best quality dental care. All dental 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. They are all trained in the appropriate uses and protection of your information. Below, we outline what our office is doing to ensure that:

Only necessary information is collected about you
We only share your information with your consent
Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols
Our privacy protocols comply with privacy legislation, standards of our regulatory body, the College of Dental Hygienists of Ontario, and the law

How Our Office Collects, Uses and Discloses Patients’ Personal Information Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how our office is using and disclosing your information. The office will collect, use and disclose information about you for the following purposes:

To deliver safe and efficient patient care
To identify and to ensure continuous high quality service
To assess your health needs
To provide health care
To advise of treatment options
To enable us to contact you
To establish and maintain communication with you
To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
To communicate with other treating health care providers, including specialists and general dentists
To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
To allow us to efficiently follow-up for treatment, care and billing
For teaching and demonstrating purposes on a anonymous basis
To complete and submit dental claims for third party adjudication, pre-approval when necessary, and payment
To comply with legal requirements, including the delivery of patients’ charts and records to the College Of Dental Hygienists of Ontario and the Canadian Dental Hygienists Association in a timely fashion, according to the provisions of the Regulated Health Professions Act
To comply with agreements/undertakings entered into voluntarily by the member of the College of Dental Hygienists of Ontario, including the delivery and or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
To permit potential purchasers, practice brokers and advisors to evaluate the dental practice
To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale and to purchase such information but only as part of the practice purchase
To deliver your charts and records to the registered dental hygienists insurance carrier to enable the insurance company to assess liability and quantify damages, if any
To prepare materials for the Health Professions Appeal and Review Board (HPARB)
To invoice for goods and services
To process credit card, debit and cheque payments
To obtain Credit Bureau report for the purpose of arranging credit terms
To collect unpaid accounts; this may include referral to a third party collection agency and may include that agency reporting unpaid accounts to a Credit Bureau
To assist this office to comply with all the regulatory requirements To comply generally with the law

By signing the consent section of this 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. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purpose of the College of Dental Hygienists of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue. Our office will not under ANY conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

I agree that I have reviewed the Privacy Policy below.

Full Name

Patient Consent

Full Name

Full Name of Witness

Today's Date

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code as follows: Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed in collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. Please do not hesitate to discuss our policies with any individual on our dental team and be assured that we are committed to ensuring that you receive the best quality dental care.

I agree

A safe and efficient way for patients to submit forms in advance and online.

Client Care

Patient Medical Information Form

Patient Medical Information | Dental Hygiene of Niagara

Title:

Full Name:

Date of Birth:

Occupation:

Employer:

Email:

Address:

City:

Postal Code:

Phone Number:

Phone Type:

Referred by:

Emergency Contact Name:

Emergency Contact Phone:

Please answer the questions below to the best of your knowledge:

Are you being treated for any medical conditions at the present time or have been treated within the last year? If yes, why?

Medical Doctor Name and Address

When was your last medical check-up?

Have there been any changes in your general health in the last year?

If you answered yes to the question above, please explain:

(WOMEN) Are you currently pregnant?

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

Do you have any allergies?

Medications:

Latex/Rubber Products:

Other (e.g. Hayfever, Foods):

Have you ever had an uncommon or adverse reaction to any medicines or injections? If yes, please explain:

If you answered yes, please explain:

Do you have or have you ever had asthma?

Do you have or have you ever had any heart or blood pressure problems?

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Have you ever had hepatitis, jaundice or liver disease? If yes, which type of hepatitis?

Do you have a prosthetic or an artificial joint? If yes, please explain:

Do you have a bleeding problem or a bleeding disorder? If yes, please explain:

Have you ever been hospitalized for any illness or operations? If yes, please explain:

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? If yes, please explain:

Do you have or have you ever had any of the following?

Please check:

Are there any conditions or diseases not listed above that you have or have had? If yes, please list:

Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease) If yes, please explain:

Are you nervous during dental treatment? If yes, please explain:

When was your last dental visit?

When did you last have dental x-rays taken?

How often do you brush your teeth?

How often do you floss?

Have you been seeing a dentist regularly?

Do any of your teeth ache?

Have you ever been advised to take antibiotics before dental appointments?

Do your gums bleed when you brush?

Do you have any pain when you chew?

Do you feel that you have bad breath?

Have you ever been in a vehicle accident or experienced any trauma to your jaw?

Have you ever had an implant surgery?

If yes, who performed the surgery?

If yes, when was the implant surgery?

Are you being followed up on by a dental specialist?

Do you have any problems with your jaw joint (pain, sounds, limited opening, locking, popping)? If yes, please explain:

Do you smoke or chew tobacco products?

Is there anything about the appearance of your teeth you would like to change? If yes, please explain:

Please list anything not mentioned above regarding your past dental history:

If this information I have given above is true to the best of your knowledge, please type your full name below:

Full name:

Today's date:

I agree that this information that I have provided above is true to the best of my knowledge.

Patient Consent Form For Collection, Use And Disclosure Of Personal Information

I agree that I have reviewed the Privacy Policy below.

Full Name

Patient Consent

Full Name

Full Name of Witness

Today's Date