PATIENT INFORMATIONPLEASE PRINTO R A L & M A X I L L O F A C I A L S U R G E R Y

If you have previously been a patient in out office, please inform the receptionist BEFORE completing this form

Are you registering for a consiltation appontment? □ Are you registering for same day surgery and consult? □(consultation and surgery the same day if our surgeons deem the patient a suitable candidate)

Name : Dr. / Mr. / Mrs. / Miss / MsPlease Circle One:

Pronounce :first name last name

first name last name

Postal Code :

Work Phone :

Email :

Postal Code : Email :

Age : Employer :

Cell Phone :

Work Phone :Home Phone : Cell Phone :

Work Phone :Home Phone : Cell Phone :

month day year / /

month day year / /

Province :

Purpose of Visit :

Family Physician :

PARENT / GUARDIAN / SPOUSE INFORMATION (person financially responsible)

DENTAL INSURANCE INFORMATION

IF YOU HAVE DUAL INSURANCE PLEASE COMPLETE INFO FOR 2nd SUBSCRIBER

GOVERNMENT COVERAGE *please present your coverage card if you are eligible with the following plans

Name :

Name of Insurance Company :

Address if different from Patient :

Subscriber’s Employer : Relationship to Patient :

Policy / Group # : Certificate / I.D # :

Subscriber’s Name : Date of Birth :

Relationship to patient : Address :

City :

Work Phone :Home Phone : Cell Phone :

SIN # :

Band Name :

month day year / /

Name of Insurance Company :

Is this a Worker’s compensation claim? : Claim # :

Social Assistance / Alberta Works & Children’s Health Benefit / AISH? I.D. # :

NIHB / First Nation / Inuit? I.D. # :

Address if different from Patient :

Subscriber’s Employer : Relationship to Patient :

Policy / Group # : Certificate / I.D # :

Subscriber’s Name : Date of Birth :

Address :

City :

Home Phone :

Date of Birth :

Health Care Number (Patient) :

Referring Dentist or Doctor :

Family Dentist :

Are you experiencing any pain at this time?Do you clench or grind your teeth?Have you had any problems with local anaesthetic (freezing)?Do you have any allergies or unusual reations to any medications or foods? (please list)

Please list all medications / pills / herbal medicines you are taking or have been taking including their frequency & dosage

Please list any disabilitiesFor women using oral contraceptives, if taking oral antibiotics you will need another form of birth control for one complete cycle.Have you had any previous serious illness? (please list)

Have you ever had a general anesthetic or previous surgeries? (please list)

Have you or any member of your family ever had a bad reaction to general anesthetic? Please specify which family member had this reaction. Exactly what was the bad reaction?

Do you have high blood pressure?Have you ever had rheumatic fever or scarlet fever?Do you have a heart murmur?Do you have any implants in your body? (heart valve, knee, hip) If yes, has your physician recommended that you receive preventative antibiotics before dental work? If yes, what is the recommendation specifically?Do you have any liver disease?Do you have any kidney disease?Do you have diabetes?Do you have any breathing or lung problems? (bronchitis, etc.)Do you have asthma? If yes, medications : Last attack: Last Hospitilization:Have you had radiation treatment for cancer?Do you suffer from osteoporosis?Have you ever been on bisphosphinates? (ie. fosamax, didrocal, actonel) If yes, how long ago?Do you suffer from reflux or other gastrointestinal disease?Do you have a history of glaucoma?Have you ever been tested for A.I.D.S. / HIV? When? : Results :Have you ever been tested for Hepatitis A, B or C ? When? : Results :Have you ever had a bleeding problem or blood disorder?Are you taking blood thinners? (anticoagulants)Have you ever had a seizure? If yes, when? What precipitated the seizure?Do you think you might be pregnant / are you nursing?Do you smoke? If so, how much?Do you use any street drugs?Are you suffering from any psychological or mental disorders and/or handicaps? Please clarify the nature of your disorder / handicap Is it well controlled?Do you drink alcohol? If so, what is your average intake per week? (number of Alcoholic Beverages)Do your suffer from sleep apnea?Height : Weight :

CONFIDENTIAL HEALTHQUESTIONNAIREO R A L & M A X I L L O F A C I A L S U R G E R Y

Name : Date :DOB : month day year / /

YES q NO q

YES q NO q YES q NO q YES q NO q

YES q NO q

YES q NO q

YES q NO q

YES q NO q YES q NO q YES q NO q YES q NO q YES q NO q

YES q NO q

YES q NO q YES q NO q YES q NO q YES q NO q

YES q NO q YES q NO q YES q NO q YES q NO q

YES q NO q

YES q NO q

YES q NO q

YES q NO q

YES q NO q

YES q NO q YES q NO q YES q NO q

YES q NO q

YES q NO q

To the best of my knowledge, the above information is correctPatient’s Signature / Legal Guardian

PERSONAL INFORMATIONCONSENT FORMO R A L & M A X I L L O F A C I A L S U R G E R Y

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, work addresses, home telephone numbers, work telephone numbers, and e-mail addresses. (collectively referred to as "Contact Information") Contact Information is collected and used for the following purposes:

•To open and update patient files

•To invoice patients and/or legal guardians or persons financially responsible for patient accounts, for dental services, to process

credit card payments, or to collect unpaid accounts.

•To process claims for payment or reimbursement from third-party benefit providers, insurance companies and government

agencies.

•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 from whomever has been written as financially responsible for the account.

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 all third party benefit providers, insurance companies and government agencies where a claim is being submitted for

reimbursement or payment of all or part of the cost of dental treatment.

•To other dentists and all other health care providers, where further information and/or discussion is required.

•To other dentists and dental specialists if the patient 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, to provide a second opinion. •To other health care

professionals such as physicians if the patient has been referred by us to the other health care professional for either a second

opinion or treatment.•

•Where we are seeking and/or providing information to the following: laboratories, radiology centres, hospitals, etc.

•To include the following when necessary, such as; videos, pictures, slides, etc., for educational purposes.

•A student and/or other dental practitioner may observe for educational purposes.

•Should any of the above information be requested, authorization is being granted to transmit electronically via email or fax

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 the prospective purchaser safeguards all personal information.

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

As part of your surgical care, a Cone Beam Computed Tomography may be required. There are certain inherent and potential risks in the use of radiation, and in this specific instance such risks have been minimized by the use of a highly collinated x-ray beam, the latest technology in x-ray detectors and the use of lead aprons.

I consent to the collection, use and disclosure of my personal information as set out above.

Date Patient Name Patient Signature / Legal Guardian