Patient Information

Yes No

Financial Information

Method of Payment

Cash Credit Card Insurance Others

Person responsible for financial matters

Self Spouse Parent/Guardian Others

If Different From Above

Primary Insurance

Secondary Insurance

Medical History

1. {{ __('enquiry.new_form.mh_physician_txt') }}

mh_physician) && $dataObj->mh_physician =='1')) checked @endif> Yes mh_physician) && $dataObj->mh_physician =='2')) checked @endif> No

2. {{ __('enquiry.new_form.mh_hospitalized_txt') }}

mh_hospitalized) && $dataObj->mh_hospitalized =='1')) checked @endif> Yes mh_hospitalized) && $dataObj->mh_hospitalized =='2')) checked @endif> No

3. {{ __('enquiry.new_form.mh_med_chk_txt') }}

4. {{ __('enquiry.new_form.mh_medication_txt') }}

mh_medication) && $dataObj->mh_medication =='1')) checked @endif> Yes mh_medication) && $dataObj->mh_medication =='2')) checked @endif> No

5. {{ __('enquiry.new_form.mh_allergies_txt') }}

None Local Anesthetic Latex/Rubber Antibiotics Others

6. {{ __('enquiry.new_form.mh_bleeding_txt') }}

mh_bleeding) && $dataObj->mh_bleeding =='1')) checked @endif> Yes mh_bleeding) && $dataObj->mh_bleeding =='2')) checked @endif> No

7. {{ __('enquiry.new_form.mh_asthma_txt') }}

mh_asthma) && $dataObj->mh_asthma =='1')) checked @endif> Yes mh_asthma) && $dataObj->mh_asthma =='2')) checked @endif> No

8. {{ __('enquiry.new_form.mh_heart_txt') }}

mh_heart) && $dataObj->mh_heart =='1')) checked @endif> Yes mh_heart) && $dataObj->mh_heart =='2')) checked @endif> No

9. {{ __('enquiry.new_form.mh_heart_transplant_txt') }}

mh_heart_transplant) && $dataObj->mh_heart_transplant =='1')) checked @endif> Yes mh_heart_transplant) && $dataObj->mh_heart_transplant =='2')) checked @endif> No

10. {{ __('enquiry.new_form.mh_prosthetic_txt') }}

mh_prosthetic) && $dataObj->mh_prosthetic =='1')) checked @endif> Yes mh_prosthetic) && $dataObj->mh_prosthetic =='2')) checked @endif> No

11. {{ __('enquiry.new_form.mh_immune_txt') }}

mh_immune) && $dataObj->mh_immune =='1')) checked @endif> Yes mh_immune) && $dataObj->mh_immune =='2')) checked @endif> No

12. {{ __('enquiry.new_form.mh_hepatitis_txt') }}

mh_hepatitis) && $dataObj->mh_hepatitis =='1')) checked @endif> Yes mh_hepatitis) && $dataObj->mh_hepatitis =='2')) checked @endif> No

13. {{ __('enquiry.new_form.mh_any_diseases_txt') }}

mh_any_diseases) && $dataObj->mh_any_diseases =='1')) checked @endif> Yes mh_any_diseases) && $dataObj->mh_any_diseases =='2')) checked @endif> No

14. {{ __('enquiry.new_form.mh_smoke_per_day_txt') }}

mh_smoke_per_day) && $dataObj->mh_smoke_per_day =='1')) checked @endif> Yes mh_smoke_per_day) && $dataObj->mh_smoke_per_day =='2')) checked @endif> No

15. {{ __('enquiry.new_form.mh_fainted_txt') }}

mh_fainted) && $dataObj->mh_fainted =='1')) checked @endif> Yes mh_fainted) && $dataObj->mh_fainted =='2')) checked @endif> No

16. WOMEN

mh_pregnant) && $dataObj->mh_pregnant =='1')) checked @endif> Yes mh_pregnant) && $dataObj->mh_pregnant =='2')) checked @endif> No

mh_birth_control) && $dataObj->mh_birth_control =='1')) checked @endif> Yes mh_birth_control) && $dataObj->mh_birth_control =='2')) checked @endif> No

mh_menopause) && $dataObj->mh_menopause =='1')) checked @endif> Yes mh_menopause) && $dataObj->mh_menopause =='2')) checked @endif> No

17. {{ __('enquiry.new_form.mh_ques_1_txt') }}

Heart Attack Rheumatic Fever Cancer Steroid Therapy Stroke Osteoporosis Medications Seizures(epilepsy) Arthritis Heart Murmur Diabetes Kidney Disease Tuberculosis Pacemaker Lung Disease Stomach ulcer Thyroid Disease Mitral Valve Prolapse Drug/Alcohol Dependency

18. {{ __('enquiry.new_form.mh_conditions_have_txt') }}

Dental History

1. {{ __('enquiry.new_form.dh_visit_txt') }}

dh_visit) && $dataObj->dh_visit =='emergency')) checked @endif> Emergency dh_visit) && $dataObj->dh_visit =='examination')) checked @endif> Examination dh_visit) && $dataObj->dh_visit =='others')) checked @endif> Others

2. {{ __('enquiry.new_form.dh_dentist_txt') }}

dh_dentist) && $dataObj->dh_dentist =='3-6-months')) checked @endif> 3-6 months dh_dentist) && $dataObj->dh_dentist =='annually')) checked @endif> Annually dh_dentist) && $dataObj->dh_dentist =='others')) checked @endif> Others

3. {{ __('enquiry.new_form.dh_dental_txt') }}

4. {{ __('enquiry.new_form.dh_brush_txt') }}

5. {{ __('enquiry.new_form.dh_dentist_txt') }}

dh_sensitive) && $dataObj->dh_sensitive =='cold')) checked @endif> Cold dh_sensitive) && $dataObj->dh_sensitive =='sweets')) checked @endif> Sweets dh_sensitive) && $dataObj->dh_sensitive =='heat')) checked @endif> Heat dh_sensitive) && $dataObj->dh_sensitive =='others')) checked @endif> Others

6. {{ __('enquiry.new_form.dh_bleed_txt') }}

dh_bleed) && $dataObj->dh_bleed =='brushing')) checked @endif> Brushing dh_bleed) && $dataObj->dh_bleed =='flossing')) checked @endif> Flossing dh_bleed) && $dataObj->dh_bleed =='never')) checked @endif> Never

7. {{ __('enquiry.new_form.dh_crack_txt') }}

dh_crack) && $dataObj->dh_crack =='1')) checked @endif> Yes dh_crack) && $dataObj->dh_crack =='2')) checked @endif> No

8. {{ __('enquiry.new_form.dh_clench_txt') }}

dh_clench) && $dataObj->dh_clench =='1')) checked @endif> Yes dh_clench) && $dataObj->dh_clench =='2')) checked @endif> No

9. {{ __('enquiry.new_form.dh_nervous_txt') }}

dh_nervous) && $dataObj->dh_nervous =='1')) checked @endif> Yes dh_nervous) && $dataObj->dh_nervous =='2')) checked @endif> No

10. {{ __('enquiry.new_form.dh_sedation_txt') }}

dh_sedation) && $dataObj->dh_sedation =='1')) checked @endif> Yes dh_sedation) && $dataObj->dh_sedation =='2')) checked @endif> No

11. {{ __('enquiry.new_form.dh_previous_txt') }}

dh_previous) && $dataObj->dh_previous =='1')) checked @endif> Yes dh_previous) && $dataObj->dh_previous =='2')) checked @endif> No

12. {{ __('enquiry.new_form.dh_ever_chose_txt') }}

Bridgework Crowns or Caps Full or Partial Dentures Orthodontic (braces) Periodontal (Gums) Treatment Root Canal

13. {{ __('enquiry.new_form.dh_satisfied_txt') }}

dh_satisfied) && $dataObj->dh_satisfied =='1')) checked @endif> Yes dh_satisfied) && $dataObj->dh_satisfied =='2')) checked @endif> No

General Release
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I hjave completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility fro fees associated with my dental treatment or dental diagnostic procedures.

Medication List

Are you currently taking any medications?

ml_medications) && $dataObj->ml_medications =='1')) checked @endif> Yes ml_medications) && $dataObj->ml_medications =='2')) checked @endif> No

If Yes, Please list your medications:

Payment Policy

The full payment for services rendered within the office is expected at the end of each appointment. For your convenience, our office will send an electronic estimate ahead of time to your insurance company and then bill directly to them upon completion of the procedure. If the claim is not processed electronically, then we will ask for your signature on the appropriate forms so we can mail out a hard copy of the dental claim to your insurance.

For any charges that are not covered by your insurance or if you do not have dental insurance, you will be responsible for the remaining cost. We accept Visa, Mastercard, American Express, Debit, and Cash.

Cancellation Policy

Please always arrive on time for your appointment. If you are running a few minutes late, please call our office to let us know. If you are significantly delayed, we may only be able to complete a partial treatment or may even have to ask you to reschedule depending on the remaining time left before the following patient’s appointment.

We require at least 48 hours (or 2 business days) notice to cancel or reschedule your appointment. This allows us time to fill in the schedule in an attempt not to waste our dentists’ and hygienists’ time. We will try to be understanding to last minute cancellations for unexpected medical or personal emergencies, but repeat occurrences of last−minute cancellations or no−shows to your appointments will incur a $50.00 fee for the disruption.

I have read and understand the terms indicated above.

COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Our office understands the importance of protecting your personal information. We will collect, use and disclose information about you for the following purposes:

Enable us to contact you (your child) to book and confirm appointments.
To advise you of treatment options
To communicate with other health−care providers, including medical and dental specialists and general practitioners
To comply with legal and regulatory requirements, including the delivery of patient’s charts and records to the Royal College or Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulatory health professions act.
To comply with agreements/undertakings entered into voluntarily by Dr. Ngoc D Steve Van, Dr. Puneet Gill or their associates with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the college in a timely fashion for regulatory and monitoring purposes.
To prepare material for the Health Professions Appeal and Review Board
To process credit card payments
To collect unpaid accounts.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the consequences of that decision, and the process.

By signing the consent section of this form, you have agreed that you have given your informed consent to collection, use and/or disclosure of your personal information for the purposes that are listen.

Patient Consent

I have reviewed the above information that explains how your office will use my personal information. I agree that Dr. Ngoc D Steve Van, Dr. Puneet Gill or their associates can collect, use and disclose personal information as set out above in the information about the office’s privacy policies according to the requirements of the Regulated Health Professions Act, the Royal College of Dental Surgeons and privacy legislations.