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Intake Form

Personal Information:

First Name:

Last Name:

Middle Name (if shown on insurance card):

Preferred Name:

Date of Birth (MM/DD/YYYY):

Home Address:

City:

Province:

Postal Code:

Telephone # (Home):

Email Address:

Cell # (for our appointment confirmation text line):

Referred By:

Family Doctor’s Name:

Phone Number:

Family Dentist’s Name:

Phone Number:

Dental Insurance Information - Government Plans

Alberta Health Care #:

AISH/Alberta Works Card:

NIHB ID#:

Band Name & #:

Private Primary Dental Insurance Information:

Insurance Company:

Group #:

Subscriber’s Employer:

Certificate or ID#:

Subscriber’s Name:

Subscriber Birth Date: (m/d/y):

Private Secondary Dental Insurance Information:

Insurance Company:

Group #:

Subscriber’s Employer:

Certificate or ID#:

Subscriber’s Name:

Subscriber Birth Date: (m/d/y):

Medical Health History:

1. Are you currently under the care of a physician?

Yes

If yes, what for?:

2. Please place an “X” in the appropriate box for the listed health issues. Indicate “Yes” if you previously had the condition, even if you do not currently have that condition. Where applicable, please circle the correct type of condition or specify.

Alcohol problems/Drug Dependency

Yes

Heart Attack/Heart Disease/Stroke

Yes

Environmental or Food Allergies

Yes

Pacemaker

Yes

Nervousness/Psychiatric condition

Yes

Asthma

Yes

Chronic Obstructive Pulmonary Disease (COPD)

Yes

Alzheimer’s Disease/Dementia

Yes

Tuberculosis

Yes

Depression

Yes

Artificial Joint Replacement

Yes

Sleep Apnea

Yes

Cancer. If yes, specify type:

Yes

Dry Mouth

Yes

Other Condition(s). If yes, specify:

Yes

Chronic Headaches

Yes

3. Are you taking prescription medications, over the counter medications, or herbal remedies?

Yes

4. Have you recently lost or gained a significant amount of weight?

Yes

Gained: (lbs)

Lost: (lbs)

5. Do you smoke, vape, or use chewing tobacco?

Yes

6. Women: Are you pregnant?

Yes

Dental Health History:

7. When was your last dental visit? DATE:

Month

Day

Year

8. Do you normally have an unpleasant odour/taste in your mouth?

Yes

9. Do you have any pain in your jaw joint?

Yes

10. Do you clench or grind your teeth?

Yes

11. Do you have dental implants?

Yes

12. Have you ever had a serious accident or trauma/injury to your neck or jaws? If yes, specify:

13. Do you have any sore spots or anomalies in your mouth?

Yes

Complete the following questions only if you have some or all of your natural teeth:

14. Do you have any dental work ongoing or outstanding at this time?

Yes

15. Do you have any sensitive teeth?

Yes

16. How often do you brush your teeth?

Daily

Weekly

Never

17. How often do you floss your teeth?

Daily

Weekly

Never

18. How often do you see a Dental Hygienist?

Yearly

Biyearly

Never

Complete the following questions only if you have a denture or dentures:

19. What type of denture(s) do you have? (Complete or Partial):

Upper:

Lower:

20. How old are your dentures?

Upper:

(years)

Lower:

(years)

21. Do your gums get sores under your denture(s)?

Upper:

Yes

Lower:

Yes

22. Do you brush your gums under your denture(s)?

Yes

23. Do you wear your denture(s) at night?

Upper:

Yes

Lower:

Yes

24. Are you happy with the appearance of your denture(s)?

Yes

25. Do you have problems eating any type of food?

Yes

26. Do you use denture adhesives?

Yes

27. Have the benefits of dental implants been discussed with you?

Yes

Personal Information Protection Act Consent Form

In our office, we are dedicated to ensuring the protection of our patients’ personal information and ensuring that this information is used only in a professional manner. The following indicates some of the information that is collected, why we collect it, and when we may disclose your personal information. We collect, use and disclose your personal information where permitted or required by law.

Contact Information

We collect contact information from our patients, such as full name, home address, home telephone number(s), work telephone number(s), and cellular phone number(s). This information is considered as Contact Information, and it is collected for a variety of purposes, including the following:

❖ To open and update a patient file;

❖ To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts;

❖ To process claims for payment or reimbursement from a third-party health benefit provider or insurance company*

❖ To correspond by mail or by telephone with our patients regarding the need for further examination or treatments; and

❖ To send correspondence to our patients regarding our clinic and practice.

* Contact information is/may be disclosed to a third-party health benefit provider or insurance company when submitting a claim on the patient’s behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

Medical/Dental History

We collect information from our patients about their health history, family health history, physical and mental condition, their dental health history and family dental health history. This Medical/Dental information is collected for a variety of purposes and may be used in part to assist us in diagnosing dental conditions and providing appropriate treatment for you, and may be disclosed for the following purposes:

❖ To a third-party health benefit provider or insurance company, in the submission of a claim on behalf of the patient, for reimbursement of payment of all or part of the cost of the treatment;

❖ To a third-party health benefit provider or insurance company on behalf of the patient, in the submission of a preauthorization of treatment;

❖ To other health/dental providers, where, upon your consent, we are seeking a second opinion;

❖ To other health/dental providers, where, upon your consent, we have referred you to additional/alternative treatment.

Future Use

If consideration to sell this practice or a portion of this practice ever occurs, qualified potential purchasers may be granted access as part of the due diligence process to patient information, in order to verify information related to the sale. If this ever occurs, we will take necessary steps to ensure that the prospective purchaser protects any personal information, as we have done.

Regulatory

The College of Alberta Denturists regulates all Denturists in the Province of Alberta, and as part of their regulatory function, may inspect our records and interview our staff in the process of their duties.

Consent

I hereby authorize and consent to the collection, use and disclosure of personal information concerning myself with regard to the above purposes.

Date at the City of

in the Province of Alberta on the

day of______, 20______.

(Patient Signature)

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(Print Name)

FINANCIAL POLICY

Option 1 – Regular Claim:

All accounts are paid by you, at the time of service, and the insurance Claim (if any) is sent electronically (when possible) by our office at the time of your appointment. The insurance payment is mailed directly to you and may be received in as little as three days.

Option 2 – Direct Billing (PLEASE READ CAREFULLY):

If choosing the direct billing option, we require a preauthorization through your insurance prior to beginning treatment. Following the response from your insurance preauthorization, your portion owing will be due at the beginning of treatment.

Each insurance provider has fee guides to calculate your coverage. Insurance providers pay a percentage of their fee guide, not a percentage of our office fee guide. All insurances have different policies, limitations and yearly maximums – because of this, it is impossible to estimate exactly how much your Insurance provider will pay, as such, please be aware that there may still be a balance owing.

I agree with the above financial policy of Leduc Denture Clinic and understand the above information.

Print:

Signature:

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Date:

Month

Day

Year

TREATMENT CONSENT & CANCELLATION POLICY

I, the undersigned, authorize Leduc Denture Clinic/River Valley Denture Clinic to perform any necessary denture services that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all denture services are my sole responsibility and that I should make myself aware of any fees associated with my denture care prior to treatment.

We have a confirmation text line to help remind you of your upcoming appointments. Please do your best to ensure you confirm your upcoming appointments using this service. *Please ensure your proper cell phone number is written down to receive these messages.*

In order to maintain our schedule effectively, we ask that you give 12 hours' notice to cancel, change or move your appointment. Should you miss more than one appointment, we will require a $50 deposit to book your next visit. Please note we do realize there are unusual circumstances or emergencies that are out of your control. Thank you for choosing Leduc Denture Clinic/River Valley Denture Clinic. We appreciate your time, cooperation and understanding. We look forward to seeing your smile soon!

Print:

Signature:

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Date:

Month

Day

Year