Book Appointment – Rosetta Dental

Confidential Patient Information

To help us meet all your dental healthcare needs we will need the following information. All information will be strictly confidential.

First Name

Last Name

Email*

Phone Number*

Street Address *

City*

Province

Postal

Country*

Birth Date *

How did you hear about us ?*

Employer Full Name*

Employer Address*

Work Phone Number*

Occupation*

Name of Insurance Policy Holder*

Birth Date*

Policy Holder Contact Phone Number

Insurance Company Name

Policy Number

What's the Certificate/Subscriber ID?

Emergency Contact*

Relationship*

Family Doctor Name?*

Doctor’s Phone number? (if available)

When was your Last Medical Check up? *

Have you ever been hospitalized or had a serious illness?* Yes No

If Yes, Please Explain why you been hospitalized or what a serious illness you had? *

Are you being treated for any medical condition at the present time or have you been treated within the past year?* Yes No

If Yes, Which medical condition at the present time or have you been treated within the past year?

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No

If Yes, Please list any medications, non-prescription drugs or herbal supplements of any kind? *

Women: Are you pregnant/ or Breastfeeding? Yes No

Nervous System: (Indicate which of the following you have had, or have at present. Headaches Convulsions/Epilepsy Dizziness/Fainting Psychiatric Treatment Trigeminal Neuralgia

Endocrine: (Indicate which of the following you have had, or have at present. Diabetes Hypoglycemia Thyroid Condition/Goiter

Bone/Muscles: (Indicate which of the following you have had, or have at present. Arthritis/ Rheumatism Artificial joints/Limbs Osteoporosis Neck Ache

Allergies: (Indicate which of the following you have had, or have at present. Local Anesthetics Latex Sensitivity Penicillin Aspirin or Codeine Sulfa Drugs Other

Respiratory: (Indicate which of the following you have had, or have at present. Asthma/ Hay Fever Sinus Problems Difficultly breathing while laying down COPD / Lung Disease

Blood: (Indicate which of the following you have had, or have at present. Bruise Easily Anemia Blood Transfusion Bleeding Disorder Excessive Bleeding/ Long Healing

Digestive System: (Indicate which of the following you have had, or have at present. Hepatitis Liver disease/Jaundice Ulcers Kidney Trouble

Immune System: (Indicate which of the following you have had, or have at present. Radiation/Chemotherapy AIDS/HIV Cancer

Are there any diseases or medical problems that run in your family ?

Do you use tobacco in any form? * Yes No

If Yes, How much do you use tobacco per day?

When was your last dental visit? *

When did you last have dental x – rays ?*

How often do you use dental floss?*

How often do you brush your teeth?*

Have you ever had local anaesthetic (freezing)?* Yes No

If Yes, Were there any complications with anaesthetic (freezing)?

Are you satisfied with your teeth/smile? specify.

Patient/Guardian Signature*

Date*

How would you like to pay for your visit ?* Cheque Cash Debit Credit Card

Patient/Guardian Signature *

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider who may release such information to you. I will notify the dentist of any change in my health or medication.

Financial Policy

Our goal is to provide patients with highest dental care and transparency. Before proceeding with a treatment all fees and financial arrangements will be discussed with you and your questions will be answered. We take the time to ensure that you understand exactly what is being done, the costs, benefits and the risks.

You will be asked to pay the fee at the time of service. You are responsible for the payment of all the fees for dental care rendered at Rosetta Dental. For your convenience if you would like we can contact your dental benefit provider so that you know what is covered. Since there is a possibility that the information given over the phone can be inaccurate, we cannot be accountable for what your benefits cover. We will submit the claim on your behalf and help you with any request your benefit provider might have.

Lateness/ No Show / Cancellation Policy: A scheduled appointment means that the Dentist and the rest of the team have reserved a time specifically for you and no other patients are seen at that time. If you know you cannot make your appointment we require 48 hours notice so that we can give your scheduled time to another patient. Patients who do not follow this policy may be charged a fee and/or may no longer remain patients of this practice.

Privacy of your personal health information is an important part of our office, providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.