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Patient Intake FOrm

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Patient Information

Name*

First Last

Date Of Birth*

MM slash DD slash YYYY

Approximate Height*

Approximate Weight*

Phone*

Email*

Street Address*

City/Town*

Postal Code*

Province*

How did you hear about our office?

Emergency Contact Information

Emergency Contact Name*

Relationship to you?*

Emergency Phone Number:*

Dental History

Previous dental office:

Use "n/a" if you didn't have a dentist.

Date of last dental exam

Date of last dental x-rays:

Do your gums bleed?*

Yes

Have you ever been told you need to take antibiotics prior to dental treatment?*

Yes

Have you ever been told you have gingivitis or periodontal disease?*

Yes

Do you have any concerns with your jaw? (ie: pain, popping, clicking, limited opening)*

Yes

Do you clench or grind your teeth? Do you wear a nightguard?*

Yes

Have you ever been screened for sleep apnea?*

Yes

Are any of your teeth sensitive to hot/cold/biting sweets?*

Yes

Are you fearful of dental treatment?*

Yes

Have you ever had any complications or an adverse reaction to local anesthetic?*

Yes

Have you ever had orthodontic treatment, or had your bite adjusted?*

Yes

Is there anything you would like to change about the appearance of your teeth?*

Yes

Medical History

Pharmacy you use

Date of Last Medical Exam?

MM slash DD slash YYYY

Are you presently under the care of a physician?*

Yes

Provide Details

Have you been hospitalized in the last 5 years?*

Yes

Provide Details

Please provide details of any major/minor surgeries and/or serious illnesses:

Are you presently being treated by a chiropractor, naturopath, or any other holistic practitioner?*

Yes

Are you currently taking any prescription/non-prescription medication, including herbal remedies, vitamins, and/or dietary supplements?*

Yes

Please Specify

Do you have any known allergies, or have you ever had an adverse reaction to any medications or injections?*

Yes

Please Specify

Are you diabetic?*

Yes

If yes, please provide your last A1C or blood glucose level:

Please check any of the following that you currently have or have had previously:*

Heart disease

Heart surgery

Heart attack

History of infective endocarditis

Prosthetic cardiac valve

Pacemaker

High/low blood pressure

Chemotherapy

Radiation

Tumor or abnormal growth

History of drug/alcohol abuse

Fainting/dizzy spells

Hepatitis A/B/C

HIV/AIDS

Liver disease

Thyroid disease

Frequent headaches/migraines

Chest pains

Gastrointestinal disorders

Emphysema

Kidney disease

Mental/neurological disorders

Rheumatic fever

Tuberculosis

Infectious disease

Chronic bronchitis

Epilepsy/seizures

Heart murmur

Mitral valve prolapse

Stroke

Stomach disorders/ulcers

Excessive/prolonged bleeding

Osteoporosis

Hip/knee/joint replacement

Anemia

Arthritis

Asthma

Sinus problems

High cholesterol

Cold sores

none

other

Please Specify

Are you a smoker, or have you smoked previously?*

Yes

Do you currently use any other tobacco or cannabis products?*

Yes

What is your approximate daily consumption?

Are you interested in ‘Botox’ therapeutic treatment for headaches/jaw pain/migraines?*

Yes

Are you interested in ‘Botox’ cosmetic treatment?*

Yes

Are you pregnant or nursing?*

Yes

Do you suffer from prostate disorders?*

Yes

Personal Information Release & Consent

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law.

We collect information from our patients such as names, addresses, telephone numbers, and email addresses (collectively referred to as “Contact Information”). Contact information is collected and used for the following purposes:

To open & update patient files
To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To send reminders to patients concerning the need for further dental examination or treatment via email and text
To send patients informational material about our dental practice

Contact Information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

“Financial Information” may be collected in order to make arrangements for the payment of dental services.

We collect information from our patients about their health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and providing safe dental treatment.

Patient’s Medical Information is disclosed:

To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment on all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf
To other dentist’s and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion
To other dentist’s and dental specialists if the patient, with their consent, has been referred to us by the other dentist or dental specialist for treatment
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion
To other health care professionals such as physicians if the patient, with their consent, has been referred to us by the other health care professional for either a second opinion or treatment

I consent to the collection, use, and disclosure of my personal information or that of my dependents as set out above. I consent to the taking of photographs and x-rays by Riverstone Dental, as they are a necessary part of record keeping.*

Yes

Release of Information

I hereby assign my benefits, payable from insurance claims submitted electronically, to Riverstone Dental Clinic, and authorize payment to their office.
I understand that my insurance policy is a contract between myself, my employer, and the insurance company. I understand that Riverstone Dental Clinic is NOT a party to this contract.
I understand that I am responsible for the fees of Riverstone Dental Clinic, and not what my insurance allows or considers “usual, customary, and reasonable,” all of which vary from one insurance company to another.
I understand that although Riverstone Dental Clinic may estimate my insurance benefits, they are not responsible for the accuracy of those benefits. Providing information regarding benefits, and benefit amounts, limitations, exclusions, waiting periods, etc, is entirely my responsibility.
I understand that all charges not paid by insurance are entirely my responsibility.

Health Benefits

Do you have Health Insurance?*

Yes

Insurance Company*

Group Plan Number*

Certificate/Subscriber ID#*

Subscriber Name*

Subscriber Birthdate

MM slash DD slash YYYY

Do you have Secondary (additional) Health Insurance?

Yes

Secondary Insurance Company*

Secondary Group Plan Number*

Secondary Certificate/Subscriber ID#*

Secondary Subscriber Name*

Secondary Subscriber Birthdate

MM slash DD slash YYYY

Financial Policy

On our patient’s behalf, our dental office will submit the primary and secondary insurance claims and request that your benefit company pays our office directly for your services. Our patients are required to pay any remaining balance at the time of the appointment, if the benefit company does not pay in full. In the event that your benefits do not tell us what they will be paying, we do require a credit card be left on file so that we can apply the difference once payment is received.

If your policy does not allow for payment directly to our office, the patient is responsible for payment in the full amount at the time of the appointment. We will submit dental claim forms on your behalf and have the insurance company reimburse you directly. If you do not have any dental benefits, we do require payment in full at the time of your appointment.

Consent

I consent to the above information, disclosure and financial policies*

Yes

Your Name*

Signature Date

MM slash DD slash YYYY

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Welcome

Patient Intake FOrm

Patient Information

Emergency Contact Information

Dental History

Medical History

Personal Information Release & Consent

Release of Information

Health Benefits

Financial Policy

Consent

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