AgeCare New Patient Form

Client Information

First name

Last name

Date of Birth

Phone number

Address (room #, street, city, postal code)

Email Address

Facility Information

Emergency Contact

Name

Phone number

Email address

Personal Directive Agent (Power of Attorney)

Do you make your own medical decisions

Yes, I make my own decisions. Do not fill out the Personal Directive section.

No, my personal directive does. Fill out the Personal Directive section below.

Name

Phone number

Insurance Information

Alberta Health Care # (Alberta Seniors Dental Benefits)

Insurance Company

Contract (Group #)

ID # (Personal ID#)

Plan Holder Name & Birthday (if different from patient)

Medical Information

Medical Conditions, Medications & Dosages

Oral Exam Consent

This information is to ensure that you are aware of the option to receive an oral health exam by a registered dental hygienist within your facility. an oral exam for patient named above for which a fee of $0, in which the dental hygienist will do a full assessment. This includes a visual oral cancer screening, hard deposits (calculus/tartar), inflammation (gingivitis & periodontitis), infection (periodontal & tooth), cracks, and dental decay (cavities/caries). Treatment planning will follow, and treatment suggested must be approved with the Guardian (Power of Attorney) before further treatment or charges.

This release also acknowledges that on this date at least two options for treatment offered:

Oral Exam Consent

Decline

Medical Information & Power of Attorney Consent

Option to release medical information & Power of Attorney to Outdoor Dental/Agecare Dental Hygiene to receive an oral health exam and/or dental hygiene treatment by this registered dental hygienist within the facility. Outdoor Dental has a Privacy Information Assessment approved under the Officer of Information and Privacy Commissioner of Alberta (OIPC of Alberta PIA #022618). Release of medical information & Power of Attorney for the above patient to AgeCare Dental Hygiene to complete an oral health exam and/or treatment in this facility.

This release also acknowledges that on this date at least two options offered to you:

Medical Information & Personal Directive Consent

Decline

Dental Hygiene Consent

This information is to ensure that you are aware of the existing periodontal disease (gum disease) and infection present in your mouth. It is to acknowledge that you have been informed of the existence of this disease and given a copy of the periodontal pocket charting. The consequence of non-treatment will likely result in a progression of this infection and, if it continues, eventual bone loss, loosening of teeth and the ultimate loss of teeth.

This release also acknowledges that on this date, you are consenting to "nonsurgical approach" to periodontal disease.

Initial fees for a cleaning can range from $ 144 - $ 381. We will predetermine costs before treatment and discuss treatment options. Intervals of cleanings can be every 3-6 months depending on disease progression and oral hygiene home care.

This release also acknowledges that on this date at least two options offered to you:

Dental Hygiene Cleaning Consent We will predetermine all costs before treatment and consult with you.

Decline

X-ray Consent

I acknowledge that x-rays will not be take.. Yearly X-rays are suggested to confirm that decay or infection are not present. Areas such as in-between the teeth, under crowns, roots, and fillings.

Today's Date

Signature of Patient (or Personal Directive Agent)

Typing your name will be your signature that this form is correct.

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