Patient Intake Form

Welcome. Please enter the patient's Year of Birth:

Patient Intake Form

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Patient Information

Last Name

First Name

Preferred Name

Date of Birth

Gender

Male Female Other

Scheduled Date

Street Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

Do you have orthodontic insurance?

Yes

Family Information

Mother’s First Name

Mother’s Last Name

Mother’s Marital Status

Same as address and contact info as patient information above

Street Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

Father’s First Name

Father’s Last Name

Father’s Marital Status

Same as address and contact info as patient information above

Street Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

Person(s) Responsible for Payments

Mother

Father

Other

Names and ages of siblings

Medical History

Patients Family Physician

Phone #

1. Are you under a physician's care at present? 1. Is your child under a physician's care at present?

Yes No

2. Are you being treated for any medical conditions? 2. Is your child being treated for any medical conditions?

Yes No

3. Are you currently taking any prescription or non-prescription medications? 3. Is your child currently taking any prescription or non-prescription medications?

Yes No

4. Are you allergic to any medications or latex? 4. Is your child allergic to any medications or latex?

Yes No

5. Have you ever had any serious illness? 5. Has your child ever had any serious illness?

Yes No

6. Have you ever been hospitalized or undergone any type of surgery? 6. Has your child ever been hospitalized or undergone any type of surgery?

Yes No

7. Have you ever had prolonged bleeding following a tooth extraction or minor injury? 7. Has your child ever had prolonged bleeding following a tooth extraction or minor injury?

Yes No

8. Are there any conditions or diseases that run in your family (e.g., diabetes, heart disease, cancer)

Yes No

9. Do you smoke or use any other tobacco products? 9. Does your child smoke or use any other tobacco products?

Yes No

Dental History

Main reason you are seeking orthodontic treatment

Patients Dentist

Date of last dental checkup Date of last Exam

How often do you:

How often does your child:

Vist your dentist?

Brush?

Floss?

Dental History

1. Are you currently experiencing dental pain? 1. Is your child currently experiencing dental pain?

Yes No

2. Have you been informed of missing or extra permanent teeth? 2. Has your child been informed of missing or extra permanent teeth?

Yes No

3. Have you had permanent teeth removed, including wisdom teeth? 3. Has your child had had permanent teeth removed, including wisdom teeth?

Yes No

4. Have you had previous orthodontic treatment or consultation? 4. Has your child ever had previous orthodontic treatment or consultation?

Yes No

5. Have you had injuries to your face, teeth, or mouth? 5. Any injuries to face, teeth, or mouth?

Yes No

6. Do you currently have untreated cavities? 6. Do any untreated cavities exist?

Yes No

7. Have you had a history of jaw or facial muscle pain? 7. Is there currently or any history of jaw or facial muscle pain?

Yes No

8. Have you experienced pain in your jaw joints? 8. Is there currently or any history of pain in your child's jaw joints?

Yes No

9. Have you had difficulty in opening or closing my jaws? 9. Is there currently or any history of difficulty in your child opening or closing their jaws?

Yes No

10. Do you clench or grind my teeth? 10. Does your child clench or grind their teeth?

Yes No

11. Do you breathe predominantly through my mouth? 11. Do you find that your child breathes predominantly through the mouth, or with their mouth open?

Yes No

12. Has your child ever sucked their thumb or finger?

Yes No

13. Does your child want orthodontic treatment?

Yes No

Is there any other oral conditions that the doctor should be aware of? Is there any other oral conditions that the doctor should be aware of?

Consent

CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of information is an important part of how our office provides high-quality care. We understand the importance of protecting your information. We are committed to collecting, using and disclosing it responsibly. We also try to be as open and transparent as possible about the way we handle your information.

In this office, Doctors act as the Privacy Information Officer.

All staff members who come in contact with your personal information have been trained in the appropriate uses and protection of your information. They are aware of its’ sensitive nature.

Our goals are to ensure that:
We only collect necessary information and we only share 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 and the standards of our regulatory body, the RCDSO, and the law

How we collect, use and disclose patients’ personal Information
This office will collect, use and disclose information about you for the following purposes:

to assess your health needs, advise you of treatment options and to deliver safe, effective, efficient patient care
to identify and to ensure continuous high quality service
to establish and maintain communication with you and to book and confirm appointments
to communicate with your general dentist and your other health-care providers, including dental specialists and physicians
to allow us to efficiently follow-up for treatment, care and billing
to provide the efficiency of our computerized check-in process your name must be displayed
for teaching and demonstrating purposes on an anonymous basis
to complete and submit dental claims for third party adjudication and payment
to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
to permit potential purchasers, brokers, accountants or advisors to evaluate our practice.
to deliver your charts and records to the dentist’s 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 process credit card payments, direct bank account debits and to invoice for services.
to collect unpaid accounts
to assist this office to comply with all 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 purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense 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 a 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.

Our office has a privacy code; copies of this code are available on request.

Patient Consent
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, and I can ask to see the Code at any time. I agree that Tolmie Orthodontics can collect, use and disclose personal information about [Full Name] as set out above in the information about privacy policies.

Dental & Patient Consent Agreement

Signature

I have read and understand the above questions and the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responibility to inform this office of any changes in my medical/dental status.

I acknowledge that I, [Full Name] have read and understood the privacy policies of Tolmie Orthodontics. By signing below, I provide my informed consent for the collection, use, and disclosure of my personal information for the purposes outlined.

I confirm the above information is accurate.

Date

Patient's Name [Patient's Name]

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Welcome. Please enter the patient's Year of Birth:

Patient Intake Form

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Do you have or have you ever had any of the following? Check all that apply:

Does your child have or have you ever had any of the following? Check all that apply:

Positive Medical History

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Negative Medical History

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Past Medical History

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How often do you:

How often does your child:

Dental History

Positive Dental History

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Negative Dental History

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CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Dental & Patient Consent Agreement

Signature