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About
Office
Team
New Patients
Dental Services
Contact
SASKATOON DENTIST
Welcoming New Patients
For your first visit to our clinic:
Please fill out our patient intake form below before your first appointment.
Patient Intake Form
1
Personal Information
2
Dental Insurance
3
Dental History
4
Medical History
5
Patient Consent
Name
*
Birth date
DD slash MM slash YYYY
Sex
*
Male
Female
Marital status
*
Married
Single
Other
Address
*
Postal code
*
Saskatchewan health card number
*
Home phone
Work phone
Cell phone
Email address
*
Receipts will be emailed
Employer
Position
Dental insurance
*
Yes
No
Emergency contact
*
Phone
*
Name of spouse or parent (if under 18)
How did you hear of our office?
*
Primary
Insurance company name
Group number
Certificate number
Division number
Name of policy holder
Birth date
DD slash MM slash YYYY
Yearly maximum
Secondary
Insurance company name
Group number
Certificate number
Division number
Name of policy holder
Birth date
DD slash MM slash YYYY
Yearly maximum
Supplementary health benefits
Yes
No
First Canadian Health
Yes
No
Status number
Reason for today's visit
*
Previous dentist
Date of last check-up/cleaning
DD slash MM slash YYYY
How often do you brush?
*
How often do you floss?
*
Are you nervous about dental treatments?
*
Yes
No
Have you ever had any complications with previous dental treatments?
*
Yes
No
Please describe:
Are you having any concerns at this time?
*
Yes
No
What are your concerns?
On a scale of 1 - 10, how satisfied are you with how your teeth look?
*
Please enter a number from
1
to
10
.
Are you interested in whitening your teeth?
*
Yes
No
Do you ever experience any of the following?
*
Bad breath
Sore gums
Bleeding gums
Clicking or popping jaw
Spaced or crooked teeth
Grinding teeth
Missing teeth
Broken fillings
Sensitive teeth
Headaches
Neck pain
Strong gag reflex
Loose teeth
None of the above
Are you currently in good health?
*
Yes
No
Please describe:
Do you smoke or chew tobacco?
*
Yes
No
Are you currently taking any type of medication?
*
Yes
No
Please list:
Are you pregnant?
*
Yes
No
Due date
DD slash MM slash YYYY
Are you currently nursing?
*
Yes
No
Are you currently taking a birth control pill?
*
Yes
No
Have you ever had any of the following diseases, medical concerns, or treatments?
*
Heart disease
Chest pain
Heart murmur
High blood pressure
Low blood pressure
Rheumatic fever
Scarlet fever
Ulcers
Arthritis
Stroke
Artificial joints
Kidney disease
Diabetes (type 1)
Diabetes (type 2)
Thyroid disease
Glaucoma
Emphysema
Cancer
Chemotherapy
Radiation
Tuberculosis
Swollen ankles
Mental Illness
Hemophilia
Excessive bleeding
Liver disease
Difficulty breathing
Neurological disorders
Autoimmune disorders
Drug/alcohol abuse
Asthma
Hay fever
Sinus problems
Bruise easily
Hepatitis A
Hepatitis B
Hepatitis C
STD
AIDS/HIV positive
FASD
ADD/ADHD
Abnormal bleeding
Fainting/dizzy spells
Nervousness/anxiety
Epilepsy/seizures
Anything else that was not listed
None of the above
Please describe:
Are you allergic to any of the following?
*
Local anesthetic
Codeine
Penicillin or other antibiotics
Sulfa drugs
Any metals
Barbiturates
Latex rubber
Iodine
Any other not listed
None of the above
Please list any other you allergic to:
Patient Consent
*
I agree
I hereby consent to allow all necessary dental procedures and services to be performed. This may include x-rays and or dental freezing. I understand there are limitations with certain procedures and in some instances, complications may occur. I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If I ever have changes in my health I will inform the doctor at my next appointment without fail.
Signature of patient or guardian
*
Date
*
DD slash MM slash YYYY
With the introduction of the new Health Privacy Act and the diversity of dental benefit packages more dentists are
not
accepting insurance as payment. We would like to be able to continue to offer our new and existing patients flexibility in paying for dental treatment with the following options.
Payment Options
*
Fee for service:
This option allows you to be in control of your insurance benefits by paying in full at each appointment for treatment and being reimbursed directly by your insurance company. This will enable you to keep personal records of all dental transactions, all insurance reimbursements, track maximum allowable benefits and you will be more aware of what your plan does and does not cover. You will not have to come in to pay outstanding balances, or receive possible refunds. Monies to insurance subscribers are generally received within two weeks when submitted electronically.
VIP express checkout:
Our VIP Express Checkout Program allows us to continue to offer you the convenience of using your insurance plan as a form of direct payment. Please complete the information below. It will be kept confidential and used only under the agreed terms.
Credit Card Authorization and Consent Form
Agree
*
I hereby authorize Viva Dental Studio to charge my credit card for any balance of account after insurance payment.
Type of card
*
Visa
Mastercard
American Express
Credit card number ends in (last four digits)
*
Expiration date
*
Name of cardholder
*
Credit card billing address
*
Signature of authorized cardholder
*
By submitting, I acknowledge the charges and assume full responsibility for said charges and agree to honour and abide by the terms of payment.