Patient Registration Form

Patient Information

*All fields required

Salutation*

saluation description

First Name*

Last Name*

Registering for child?*

Yes
No

Date of Birth*

Contact Information

Email*

Land Line Phone*

Cell Phone*

Work Phone*

Address*

Street Address City Province Postal Code

In case of emergency, please notify:

Emergency Contact Name*

Emergency Contact Relation*

Emergency Contact Home Phone*

Emergency Contact Cell Phone*

Emergency Contact Work Phone*

Contact Options

I prefer appointment reminders by*

Phone
SMS
Email

Whom may we thank for referring you?*

Do you agree to receive email communications, including marketing and industry updates, from Gordon Street Dental?*

Yes
No

Are any other members of your family patients at our practice?*

Yes
No

Name of Patient(s) :

Insurance Information*

Yes, insurance applies to me
No, insurance does not apply to me

Please complete the following if you have dental insurance

Name of insured/subscriber*

Date of Birth*

Patient's relationship to subscriber*

Self
Spouse
Child

Address

Same as previous

Street Address City Province Postal Code

Address

Same as previous

Street Address City Province Postal Code

Place of employment*

Insurance Company*

Policy/Group#*

Certificate/ID#*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*

Yes

Secondary insurance applies to me :*

Yes
No

Please complete the following if you have secondary dental insurance

Name of insured/subscriber*

Address

Street Address City Province Postal Code

Date of Birth*

Patient's relationship to subscriber*

Self
Spouse
Child

Address

Same as previous

Street Address City Province Postal Code

Address

Same as previous

Street Address City Province Postal Code

Place of employment*

Insurance Company*

Policy/Group#*

Certificate/ID#*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*

Yes

Medical History

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. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?*

Yes
No

What condition (please specify)?

Date

When was your last medical check-up?*

Has there been any change in your general health in the past year?*

Yes
No

Please Explain:

Are you taking any prescription, non-prescription medications, or herbal supplements?*

Yes
No

Please Explain:

Do you have any allergies?*

Yes
No

Please Specify (Environmental, or Drugs):

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes
No

Please Explain:

Do you have or ever had asthma?*

Yes
No

Do you have or ever had any heart or blood pressure problems?*

Yes
No

How was it treated ?*

Have you ever/do you have an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

Yes
No

Please Specify:

Do you have a prosthetic or artificial joint?*

Yes
No

Please Specify:

Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)*

Yes
No

What conditions do you have?*

Have you ever had hepatitis, jaundice, or liver disease?*

Yes
No

What conditions do you have?*

Do you have a bleeding problem or bleeding disorder?*

Yes
No

Please Specify:

Have you ever been hospitalized for any illnesses or operations?*

Yes
No

What for ?

Do you have, or have ever had any of the following? Please check.

Are there any conditions/diseases not listed that you have or have had?*

Yes
No

Please Specify:*

Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)?*

Yes
No

Please Specify:

Do you smoke or chew tobacco products?*

Yes
No
Not Sure/Maybe

What products and how often?

Are you nervous during dental treatment?*

Yes
No

Please rate from 1-10 and the reason:

For women only: Are you pregnant?*

Yes
No

How many months and have there been any complications ?

what is your expected delivery date?*

For women only: Are you breastfeeding?*

Yes
No

Dental History

Do you have any specific dental concerns? Please list (ex. broken tooth, hot or cold sensitivity, bleeding gums)*

When was your last dental appointment?*

How often do you see the dentist?*

Is there anything about the appearance of your teeth that you would like to change?*

Have you ever whitened (bleached) your teeth?*

Have you felt uncomfortable or self-conscious about the appearance of your teeth?*

Have you been disappointed with the appearance of previous dental work?*

Dr. Mark Lansdell, D.D.S.

Family Dental Care

848 Gordon St., Suite 102 Guelph, ON N1G 1Y7 (519) 821-7439	info@drlansdell.com www.gordonstreetdental.com

PATIENT CONSENT FORM: FOR COLLECTION, USE,
AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using, and disclosing your personal information responsibly. It is important to us to provide this service to our patients.

In this office, Dr. Mark Lansdell, D.D.S. acts as the Privacy Information Officer. All staff members who come in contact with your personal 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.

Only necessary information is collected about you;
We only share your information with your consent;
Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

Do not hesitate to discuss our policies with me or any member of our office staff

PATIENT CONSENT

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking 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. Mark Lansdell, D.D.S. Gordon Street Dental Office can collect, use and disclose personal information about (type name here) as set out above in the information about the office's privacy policies.

Name of Patient*

Signature of Patient/Parent or Guardian*

*

I agree to receive emails with related information and updates.

848 Gordon Street

(519) 821-7439

(519) 993-0912

Book Appointment

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Medical History

Dental History

Dr. Mark Lansdell, D.D.S.

Family Dental Care

PATIENT CONSENT FORM: FOR COLLECTION, USE,
AND DISCLOSURE OF PERSONAL INFORMATION

Do not hesitate to discuss our policies with me or any member of our office staff

PATIENT CONSENT

Gordon Street Dental

Our Services

Opening Hours

Book Appointment