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108 Kingsway Mall, Edmonton, AB T5G 3A6
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780-471-2102

Step 1 of 3 - General & History

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PERSONAL INFORMATION (Please Print)
Name*
First Middle Last
Date of Birth*
Sex
- Male
- Female
Mailing Address*
City
Province
Postal Code
Email:
Phone : Home
Bus
Cell:
Employer
Marital Status
Name of Spouse
If patient is a minor, who is legally responsible?
Personal Physician
Is another member of your family or relative a patient at our office? if so who?
Medical History
The following information is required to thoroughly diagnose any condition and to give the highest possible standard of professional service. All information will be kept strictly confidential.
Are you currently in good health ?
- Yes
- No
Date of your last medical examination :
Are you under the care of a physician?
- Yes
- No
If so, what is the condition being treated :
Have you had any serious illness or operation / or have you ever been hospitalized?
- Yes
- No
If so, please specify :
Are you taking any drug or medicine including herbal supplements (prescription or non-prescription)? If so, please specify.
- Yes
- No
Please enter details
Have you reacted adversely to any drug or medicine? e.g. local anaesthetic (freezing); penicillin, erythromycin or other antibiotics; barbiturates, sedatives, analgesics (pain killers) i.e. codeine, ibuprofen?
- Yes
- No
If so, please specify :
Do you have any allergies?
- Yes
- No
If so, please specify :
Do you presently or have you ever had: (please check applicable conditions)
- AIDS
- Anernia
- Arthritis
- Asthma
- Bladder Infection
- Blood Disorder
- Cancer
- Diabetes
- Epilepsy
- Hay fever
- Heart Murmur
- Heart Problems
- Bleeding Problems
- High/Low Blood Pressure
- HIV intection
- Hyper/Hypo Giycemia
- kidney Disease
- Liver Disease (Hepatitis/jaundice)
- Lung Disease
- Mental/Nervous Disorders
- Migraine Headaches
- Rheumatic Fever
- Rheumatism
- Scarlet Fever
- Sinus Trouble
- Stomach (Intestinal) Ulcer
- Stroke
- Thyroid Problem
- tuberculosis
- Venereal Disease
- joint Replacement/Implants
- None
Have you ever had radiation treatment? (i.e. Cancer)
- Yes
- No
Have you ever taken cortisone or steroids?
- Yes
- No
Is there any history of family disease?
- Yes
- No
If so, please specify :
Do you have any disease or problem not listed above you think I should know about?
- Yes
- No
(Women Only) Are you pregnant or nursing?
- Yes
- No
In the last 24 hours, as there been any new onset of a cough, chills fever or diarrhea?
- Yes
- No
Any recent exposure to measles, tuberculosis, chickenpox or any other communicable diseases?
- Yes
- No
Any recent travel to areas where endemic diseases are present?
- Yes
- No
Dental History
Is your drinking water fluoridated?
- Yes
- No
How frequently do you see your dentist / dental hygienist?
- Yes
- No
- 6 Month
- Yearly
- Other
Last dental visit
Previous dentist
Have you ever been given oral hygiene instruction in:
- Brushing
- Flossing
How often do you brush your teeth?
How often do you floss your teeth?
Do you have any lumps/sores in your mouth?
- Yes
- No
Are any of your teeth sensitive to:
- Cold
- Hot
- Sweet
Do your gums bleed:
- Yes
- No
When do your gums bleed?
- Brushing
- flossing
- Both
- Spontaneously
Do your gums feel swollen or tender?
- Yes
- No
Does food catch between your teeth?
- Yes
- No
Are you aware of any loose teeth?
- Yes
- No
Does your jaw crack, pop or grate when you open widely?
- Yes
- No
Do you grind your teeth or clench your teeth, or bite your nails? (please select all that apply)
- Grind Teeth
- Clench Teeth
- Bite Nails
Have you ever had facial pain?
- Yes
- No
Have you ever had injuring to your face or jaws?
- Yes
- No
Do you gag easily during dental visits?
- Yes
- No
(Children Only) Does your child have a thumbsucking habit or other habits? Please specify
- Yes
- No
Are you satisfied with the appearance of your teeth? If not, please specify
- Yes
- No
Have you ever had any problem associated with any previous dental experience?
- Yes
- No
Please rate your level of anxiety towards dental visits from 1 (low) to 10 (high):
Are you a regular consumer of tobacco, alcohol, coffee or tea? (Please circle which one(s))
- Yes
- No
If so, how much do you consume on a daily basis?
What dental condition concerns you at present?
Relationship to Patient*
Print Name of Parent / Guardian
First Last
Signature*
Date*

Affinity Dental Kingsway Patients
As you are aware, you are fully responsible for the payment of your dental account.

When an appointment is booked, that time is reserved exclusively for you and anyone else requesting time will be denied. For this reason, a minimum of 2 full business days notice is required to change your appointment. Failure to provide notice will result in a minimum of a $100 cancellation fee.

If you do not have dental insurance, you will be required to pay your account in full after each visit. If you have a dental plan, we would be happy to direct bill your insurance company on your behalf. However, your patient portion is due at the end of each appointment. If there is a balance remaining after submitting to your insurance company, this balance will be your responsibility. All overdue accounts will be subject to interest charges.
I would like to accept your courtesy service and have you bill my insurance on my behalf. I am now aware that the dental office is not contacted by the insurance company or employer for changes*
- Yes
- No
My Insurance Information
Plan 1
Name
First Last
DOB of Member
Relationship (i.e. self, spouse, parent)
Insurance Company
Employer (that plan is through)
Group / Plan / Policy #
I.D. / Certificate #
Plan 2 (if applicable)
Name
First Last
DOB of Member
Relationship (i.e. self, spouse, parent)
Insurance Company
Employer (that plan is through)
Group / Plan / Policy #
I.D. / Certificate #
It is your responsibility to know what benefits your insurance covers, how often services can be performed, annual maximums, and percentages.
I have read the above and agree to accept responsibility for my dental account. "My dental account" is defined as any costs incurred by any and all persons or family members receiving dental treatment and or receiving benefits on the same insurance plan at any time. Should any conditions change, I agree that it is my responsibility to notify Affinity Dental Kingsway of these changes before any costs are incurred.
Name*
First Last
Signature*
Date*

APPENDIX 5
Dental Office Personal Information Consent Form
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 that 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, home addresses, workaddresses, home telephone numbers, work telephone numbers, e-mail addresses, and patient photographs (collectively referred to as "Contact Information"). Contact information is collected and used for the following purposes:
- To open and update files.
- To invoice patients for dental services, to process credit card payments, or to coiled unpaid accounts.
- To process claims for payment or reimbursement from third party health benefit providers and insurance companies via electronic submission (CDA Net) or by mail.
- To send reminders to patients concerning the need for further dental examination or treatment.
- 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, their family health history, physical condition, and dental treatments. (Collectively referred to as "Medical Information") Patients' Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patients' Medical 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 dental treatment or has asked us to submit a claim on the patients' behalf.
- To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
- To other dentists or dental specialists if the patient with their consent has been referred by us to 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 by us to other health care professional for either a second opinion or treatment.
If we are ever considering selling all or part of our dental practice qualified potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all of the information.

Dentists are regulated by the Alberta Dental Association and College whom may inspect our records and interview our staff as part of the regulatory activities in the public interest.

I consent to the collection, use and disclosure of my personal information as set out above.
Name*
First Last
Date*

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Step 1 of 3 - General & History

PERSONAL INFORMATION (Please Print)

Medical History

The following information is required to thoroughly diagnose any condition and to give the highest possible standard of professional service. All information will be kept strictly confidential.

Dental History

Affinity Dental Kingsway Patients

My Insurance Information

Plan 1

Plan 2 (if applicable)

APPENDIX 5