Glenshton Dental

Patient Full Name:
Today's Date:
Gender:	Male Female
Married Single	Child Other
Birth Date:
Name of Spouse
Names of Children
Phone (Home):
Phone (Work):
Ext
Best time to call:
Mobile
Email

Insurance Holder's Information

Primary Insurance Plans

Name of Insured:
Is insured a patient?	No Yes
Insured's Birth Date:
ID/Cert #:
Group #:
Insurance Plan Provider:
Insured's Employer Name:
Patient's relationship to insured:	Self Spouse Child Other

Secondary Insurance Plans

Name of Insured:
Is insured a patient?	No Yes
Insured's Birth Date:
ID:
Group#:
Insurance Plan Provider:
Insured's Employer Name:
Patient's relationship to insured:	Self Spouse Child Other

Financial Polices

Your insurance benefits are between you, your employer and your insurance company. Any benefit difference (deductible, fee guide, ineligible service or co-payment) is your responsibility.

A service charge of 1½% per month (18% per annum) on the unpaid balance may be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

All estimates for approximate.

Privacy act:

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. I understand that Glenashton Dental Office has a privacy act & will take the steps 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.Harbans Singh Bamrah/ Glenashton Dental Centre can collect use and disclose personal information about myself as set out in the privacy act. I hereby assign my benefits, payable from claims submitted electronically to Dr. Harbans S. Bamrah and authorize payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.

General Release

I, the undersigned, certify that all of the information I have completed is correct and that I have not knowingly omitted data. I understand that the information contained in the medical and dental history is important to my treatment and if I ever have any change in my health, I will inform the doctors at the next appointment without fail. 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 for fees associated with my treatment or dental diagnostic procedures. I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.
I have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent, guardian, or guarantor of payments
Date:

Printed Name of patient, parent, guardian, or guarantor:
Dentist Signature

Preferred appointment times:	Morning Afternoon Evening Any Time
	M T W T F S
Address:
Street
Apartment #
City
Province
Postal Code

Name of Previous Dentist:
Dentist Telephone Number
Date of Last Dental Visit:
Reason for this visit:
Upload Document:

Family history of adverse anesthetic outcomes	No Yes
Do you have bad breath or a bad taste in your mouth?	No Yes
Do your jaws crack, pop, or grate when you open widely?	No Yes
Are you satisfied with your teeth?	No Yes
please explain:
Have you ever had any complications following dental treatment?	No Yes
please explain:
Have been to a hospital or needed emergency care during the past two years?	No Yes
please explain:
Are you now under the care of a physician?	No Yes
please explain:
Name of Physician:
Phone
Do you have any health problems that need further clarification?
Do you smoke? How much per day?

New Patient Form Download Form

Health Information

Have you ever had any of the following? Please check those that apply:

Adverse effects to any of the following:

Referral Information

Special Concerns: