Welcome to Cabbagetown Dental Centre

Patient Information

Last name

First Name

Preferred Pronoun

He/Him

She/Her

They/Them

Other (please specify):____________

Address

Unit #

City

Postal Code

Date of birth

OHIP (Ontario Health Insurance Plan) Card #

Cell phone number

Home phone number

Work Phone and ext

I consent to receive text messages from Cabbagetown Dental Centre.

By checking this box, you agree to receive text messages (e.g. appointment confirmation, reminders or any other relevant information regarding appointments) from Cabbagetown Dental Centre at the cell phone number provided on this patient registration form. You can withdraw your consent at any time by calling us at 416-927-7600 or emailing us at cabbagetowndental588@gmail.com.

Email field

Person responsible for account

Self

Other

If other, please indicate the person's name

Emergency Contact Person

Relationship

Phone Number

Whom may we thank for referring you to our practice?

Google

Online/Social

Lives nearby

Other

Insurance Information

Do you have dental insurance?

Yes

Upload Insurance Card both front and back

Add file

Please upload a file

Name of insurance policy holder

Policy holder's date of birth

Insurance Carrier (e.g. Manulife, Sunlife, ODSP etc.)

Policy/Group/Plan #

Cert./Member ID #

Employer Name

Occupation

Secondary Insurance Information

Do you fall into another family member's dental insurance?

Yes

Upload Insurance Card Front and Back

Add file

Please upload a file

Name of insurance policy holder

Policy holder's date of birth

Insurance Carrier (e.g. Manulife, Sunlife, ODSP etc.)

Policy/Group/Plan/Contract #

Cert./Member ID #

Employer Name

Occupation

We offer direct billing to insurance companies (provided that your plan is set up for direct billing). By assigning your benefits to be payable to our practice, we may send predetermination to your insurance/s prior to the day of your appointment to ensure that you have active coverage and that proposed treatments will be covered . Otherwise, insurance payments will not be guaranteed. Please check the box that applies.

I Provide consent.

YES

Dental History

Reasons for your visit?

When was your last dental visit and what was done?

Previous Dentist

Location/City/Province

frequency of use

Please check any of the following problems that might apply to you

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding Gums

Broken teeth or fillings

Jaw joint pain/Clicking

Sensitivity (hot, cold and/or sweet)

Bad Experience

Any other dental conditions

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

Dentures

Braces

Periodontal (gum) treatments

Difficult extractions

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality.

1. Has there been any change in your general health in the past year?

Yes

If yes, please explain

2. Are you currently taking any medications, non-prescription drugs or herbal supplements?

Yes

Add another medication

3. Do you have any of the following allergies?

Penicillin

Codeine

Latex

Local anesthetic

Sulpha

Other

4. Do you have a heart problem of any kind?

Yes

If yes, please explain

5. Have you ever had a heart murmur, mitral valve prolapse or rheumatic fever?

Yes

If yes, please explain

6. Have you been advised by your doctor to take antibiotic before dental treatment?

Yes

7. Women only: are you pregnant or breast feeding?

Yes

8. Have you ever been hospitalized for any illness or operations?

Yes

If yes, please explain

To my knowledge, the above medical and dental information is correct:

Name of Patient / Parent / Guardian

Date

Office Policy (Please read)

We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own rules and exceptions. We will do our best to help you clarify your plan. However, it is the patient's responsibility to understand his/her own dental insurance benefits. Unless otherwise agreed upon, services are to be paid for at each visit as they are performed.

We require a minimum of 2 business days notice (excluding Sunday) if you need to cancel or reschedule your appointment. Otherwise, this request will be subject to $75 insufficient notice fee. This applies to missed appointments as well. Such fee is the patient's responsibility as insurance will not cover a broken appointment.

Any appointment times you are offered will not be finalized until we have confirmed with you via phone/email.

I consent to the sharing of personal information about myself or my dependents with relevant dental/healthcare providers to facilitate treatments and with my insurance company for the purpose of processing insurance claims and the determination of benefits. I further agree to receive electronic messages in regards to communicating appointments, company news and updates which can be withdrawn at any time. I authorize the Dentists at Cabbagetown Dental Centre to perform all dental or diagnostic procedures agreed to be necessary , including x-rays, photographs, and the use of local anesthetic or other prescribed drugs as indicated.

Name of Patient / Parent / Guardian

I agree that the typed name above will be the electronic representation of my legal signature. By signing electronically, I am certifying that I have read, understand and agree to the office policy stated in this online form.

Date

Your information will be encrypted.