Medical/Dental History Form
We truly want to improve your dental health in the most comfortable and safe way possible. It is extremely important for you to complete your Medical/Dental history form for our office as accurately as possible.
A medical and dental history form allows our dentists to be well-informed about any allergies or health conditions you may have. You may wonder why it is important for dentists to know your medical history and your medications. The reason is, that some medications that you take on a regular basis may impact your course of dental treatment. In the event that you may need a prescription for a dental infection, it is important for the dentist to know your current medications and allergies and medical conditions so that we may avoid any drug interactions and allergic reactions.
Knowing your medications can help your dentist improve your dental health. Certain medications can be the underlying cause of many dental issues, for example, some medications cause dry mouth which in turn not only increases the risk for cavities but can also lead to gum disease. There are also some medications that have negative interactions with certain types of anesthetics, the type of anesthetic you are given before dental surgery may depend on which medications you are on.
Your information is kept confidential
Informing us of any health conditions and allergies can also help us to better understand your oral health. Your medical history is very important to us. Some health conditions like diabetes and some medications like steroids, reduce the effectiveness of your immune system. Poor immunity could be the underlying cause of any oral health issues you may have, and this may be beneficial for the dentist to know. Our dentists never want to put our patients in a position where their health and immunity could be compromised
We appreciate if you could either download and print your forms and fill them out at your convenience before your appointment or fill out the online form below. If you have any questions about our forms, we would be happy to answer those for you either at your appointment or over the phone. We look forward to meeting you!
PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and as transparent as possible about the way we handle your personal information. It is VERY important to us to provide this service to all of our patients. In this dental office, the dental centre manager acts as the privacy information officer. All team members who have 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. Here is an outlined policy that our office follows to ensure you that:
- Only necessary information is collected about you
- We only share your information with your consent
- Storage, retention and proper destruction of your personal information complies with the existing legislation and privacy protection protocols
- Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law
Please do not hesitate to discuss our policies with me or any member of our office staff and be assured that every team member in our office is committed to ensuring that you receive the best quality dental care.
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 here how our office is using and disclosing your information. This office will collect and 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 access your health needs
- To advise you of treatment options
- To establish and maintain communication with you
- To enable us to contact 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 healthcare providers, including specialists and general dentists who are referring dentists and/or peripheral 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 effectively follow-up for treatment, care and billing
- For teaching and demonstrating purposes on an anonymous basis
- To complete and submit dental claims and estimates for third party adjudication and payment
- To comply with legal and regulatory requirements, including the delivery of patient’s 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 comply with agreements/undertakings entered into voluntarily by the member with the patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
- To permit potential purchasers, practice brokers or advisors to evaluate the dental practice
- To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
- 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 should occur
- To prepare materials for the Health Professions Appeal and Review Board (HPARB)
- To invoice for goods and services
- To process credit card, cash and personal cheque payments
- To collect unpaid accounts
- To assist this office to comply with all regulatory requirements
- To comply generally with the law
By signing this consent section of this patient consent form, you agree 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 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 your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
I have reviewed the above information that explains how Dentistry Dunnville will use my personal information and the steps that Dentistry Dunnville is taking to protect all of my personal information. I agree that DENTISTRY DUNNVILLE can collect, use and disclose personal information as set above in the information about Dentistry Dunnville’s privacy policies.
CONSENT TO THE ADMINISTRATION OF LOCAL ANESTHETIC BY INJECTION
Any administration of local anesthetic by injection caries a risk of complications occurring. The following is a list of SOME of the most common OR most serious complications to occur in conjunction with any injection of local anesthetic:
- needle breakage
- soft tissue injury
- syncope (fainting)
- allergic reaction (mild or severe)
- intravascular injection
- more rarely; nerve damage resulting in areas of numbness, tingling or burning or other reduced/altered sensation (anesthesia/paresthesia). These can be temporary or permanent and involve any area of the head and neck including but not limited to the tongue, lips, cheeks, chin, neck, and face.
I understand that the alternatives to the use of local anesthetic are a general anesthetic or not using any anesthetic.
I have discussed all of the above with the doctor, and have had all of my questions answered to my satisfaction.
MEDICAL, DENTAL AND HEALTH HISTORY
The information that is requested on this questionnaire, dental history is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting,using and disclosing this information responsibly.
PLEASE PRINT REGISTRATION INFORMATION
INSURANCE BENEFIT DETAILS
SINCE THE INTRODUCTION OF THE PRIVACY ACT IT HAS BECOME INCREASINGLY DIFFICULT FOR US TO OBTAIN INFORMATION REGARDING YOUR DENTAL BENEFITS AND COVERAGE LEVELS. SHOULD YOU WISH FOR US TO HELP YOU UNDERSTAND YOUR COVERAGE DETAILS PLEASE CALL YOUR INSURANCE CARRIER AND REQUEST THE INFORMATION BELOW. THIS WILL HELP US ASSIST YOU BETTER.
PROVIDED BY DENTAL OFFICE