Name
*
First Name
Last Name
Email
*
Home Phone
(###)
###
####
Mobile Phone
(###)
###
####
Work Phone
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Employer Name
Date of Birth
*
MM
DD
YYYY
Age
Gender
*
Male
Female
Other
Marital Status
*
Single
Married
Divorced
Widowed
Common Law
Dentist
*
Dentist Phone Number
(###)
###
####
Family Doctor
*
Family Doctor Phone
(###)
###
####
Health Card Number
*
Expiry Date
*
MM
DD
YYYY
Do you have Dental Insurance?
*
Dental Insurance Information
Please provide your dental insurance information below including Insurance company, Plan/Group #, ID#, Policy Holder Name and DOB. If you have more than one plan, please provide the information for both plans. Please note: payment is due when services are rendered (cash, VISA, MC or Interac).
Medical Information
Have you ever had or currently have any of the following conditions.
Are you or could you be pregnant?
*
Yes
No
Are you nervous about dental treatment?
*
Yes
No
Do you want to be sedated (put to sleep) for surgery?
*
Yes
No
Medications
Please list all medications that you are currently taking.
Allergies
Please list all your allergies.
Do you smoke?
Yes
No
How did you hear about us?
*
Dentist
Family Doctor
Online Search Engine
Friend / Family
Signage
Other
Consent For Personal Information
*
I have reviewed the 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 Dr. A. Mobini can collect, use and disclose personal information as set out in the information about the office's privacy policies.
Consent for Oral Surgery & Anesthesia
*
I hereby give consent for oral surgical procedure deemed necessary by my oral surgeon and administration of local and/or general anesthesia as needed for those procedures. I understand that possible complications include bruising, bleeding, swelling, infection, opening into maxillary sinus, temporary or permanent loss of sensation to lip, teeth, gum, chin or tongue, injury to adjacent teeth/fillings. I have read and understand the above and hereby give consent.
Consent for Electronic Submission to Insurance Company
*
I authorize release, to my dental insurance carrier administrator and CDA/ITRANS, information contained in claims submitted electronically. This authorization shall continue in effect until the undersigned revoked the same.
