Dental Intake Form

Privacy Policy: The information in this form is required to enable us to provide you with the best possible dental care. Cataraqui Woods Dentistry complies with all relevant privacy laws and regulations. Any information that you communicate to Cataraqui Woods Dentistry is safe, secured, and encrypted.

Welcome to Cataraqui Woods Dentistry!

If you are an existing patient with us already, please visit our Request an Appointment form.

Please note that this form cannot be submitted if fields marked with an asterisk (*) are left blank.

Patient's Personal and Contact Information

First Name

Last Name

Street Name and Number

City Name

Province

Postal Code

Date of Birth

Prefer to be called

Primary Contact Number

Health Card Number

Employer and Occupation

Physician Name

Physician Phone Number

Street Name and Number

City Name

Province

Postal Code

Who may we thank for your referral?

If this box is showing, you have accidentally entered a future date into the DOB field. If you are unable to correct this or the calendar has malfunctioned, tick this box.

Street Name and Number

City Name

Province

Postal Code

Primary Contact Number

Which days are you available? Check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

I am available on all of these days.

Which time slots are you available? Check all that apply.

8:00 AM to 12:00 PM

4:00 PM to 8:00 PM (Tuesdays only)

12:00 PM to 4:00 PM

I am available during all of these times.

Emergency Contact Person(s)

Name (first and last)

Relationship

Phone Number

Name (first and last)

Relationship

Phone Number

Insurance Information

Please remember to bring your insurance card/information with you during your first appointment.

You be required to pay the full bill out of pocket without proof of insurance documentation.

Which insurance company are you with? Please do not list your place of employment. If you claim your benefits through a particular healthcare plan (ie, a private plan), please provide their plan administrator.

If you do not have insurance, type "OOP" for Out of Pocket

Is there any additional insurance information you think we should know?

Medical History Questionnaire

Please specify the medications, non-prescription drugs, or herbal supplements that you take.

Please specify your allergies or allergic reactions.

Please specify any unusual reactions you have had to drugs or medicine.

Please specify any drugs or medications that you have been warned against taking.

Please specify the pre-medication for dental treatment that you require.

Please specify any organ or medical implants that you have had.

You selected "other," please explain further.

Are there any accomodations that we can make for your disability?

15. Is there anything else regarding your medical history that we should be aware of?

If there is nothing else, please type "Nothing else."

13. Is there anything else regarding your medical history that we should be aware of?

If there is nothing else, please type "Nothing else."

Dental History Questionnaire

1. Which dental problems are you currently experiencing?

Tooth pain

Bleeding gums

Grinding/clenching teeth or Jaw joint pain

Broken teeth or fillings

Sensitivity (hot, cold and/or sweet)

Not experiencing any of the above

3. How often do you brush or floss your teeth?

Where? For how long did they / have they been occuring?

What daily quantity of substance do you smoke or vape?

For example, one pack of cigarettes per day.

15. Is there anything else regarding your dental treatment that we should be aware of?

If there is nothing else, please type "Nothing else."

Assignment of Benefits Disclaimer

As your dental provider, we try our best to learn all that we can about your dental benefits. However, there are numerous service providers and over 30,000 dental benefit plans in Ontario. We cannot always gain complete access to the full details of your benefits package. Your particular plan may not cover the full cost of your dental visit. We cannot guarantee that your insurance provider will fully cover your treatment.

Predeterminations Disclaimer

Due to the Privacy Act, your insurance company will not provide us with the results of any of your dental predeterminations. You are responsible for contacting your insurance company to find out the results. We will require you to provide us a copy of your estimate response prior to your appointment to allow us to ask your insurance provider to pay us directly and assume your co-payment. Without this estimate, you will be responsible for the full payment at the time of treatment.

I acknowledge that I have fully read and understood the Assignment of Benefits Disclaimer and the Predeterminations Disclaimer.

I agree that payment for dental services is expected when treatment is rendered. I agree that my dental benefits may not cover the full cost of treatment. I agree that I am exclusively liable for all outstanding balances pertaining to myself or to my dependents, if any. I agree to give 48 hours notice if I am unable to keep a reserved appointment due to circumstances within my control, and understand that charges for time lost may be incurred if I do not provide the required notice.

I consent and authorize all dental professionals at Cataraqui Woods Dentistry to perform diagnostic procedures and treatments as they see fit for proper dental care insofar as they are in full compliance with their appropriate regulatory bodies.

I fully understand that all the information I have supplied will be used and disclosed in full compliance with all relevant federal and provincial privacy laws and legislation, such as and including but not limited to the Privacy Act, PIPEDA, and PHIPA. I consent and authorize Dr. Wajahat Khan (registration number 53237) or any person authorized by him, to reproduce any personal dental information which he has collected as part of my dental record to all outside agencies (such as and including but not limited to my medical doctor/physician), that have requested such information from Dr. Khan, and that this will be without compensation to me. I hereby release Dr. Khan and any third party, who may make use of such information, as contemplated by this release and consent, from any and all claims arising out of or in conjunction with such use.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history, and have not knowingly omitted any information.

Date

If this box is showing, you have accidentally entered a future date into the DOB field. If you are unable to correct this or the calendar has malfunctioned, tick this box.

Patient/Parent/Guardian Electronic Signature

I understand that my electronic signature is of the same legal equivalence to my physical signature.

Thanks for joining the Cataraqui Woods Dentistry family!

If you've sent this new patient form during our business hours, we'll start working on it right away.

If you've sent this outside of our business hours, we'll receive at 8:00am, Monday to Friday.

Sincerely,

Cataraqui Woods Dentistry

Your information will be encrypted.