3173 Erindale Station Road, Mississauga, Ontario L5C 1Y5 | 905-270-4444 | reception@erindalevillagedental.ca

New Patient Health History & Registration

Health History & Registration
Feel free to contact us if you have any questions
PATIENT INFORMATION

If Patient is a Minor PLEASE FILL OUT PORTION BELOW

PARENT OR GUARDIAN INFORMATION
DENTAL INSURANCE INFORMATION (Primary Carrier)
EMERGENCY INFORMATION

It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.

DENTAL HISTORY
MEDICAL HISTORY

Please select any of the following which you have had or presently have:

Are you allergic to or have you reacted adversely yo any of the following medications?

COVID-19

  

Financial Policy

We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. If you have questions , please discuss them with our financial team members.

Erindale Village Dental is pleased to offer you the following payment options.

Option 1: 

Payment is due in full the day treatment is rendered. We accept cash, certified cheques, debit, Visa, and MasterCard. 

Option 2: 

Your insurance company may require you to, or you may prefer to, pay for your dental work directly on your treatment day, and have your insurance company reimburse you. Erindale Village Dental will process your payment on the date treatment was rendered. Our team members will assist you in submitting the necessary documents to your insurance carrier.

Option 3:

You may leave your credit card number on file (secure database) and we will directly bill your insurance company, you don't have to wait around on your treatment day. Once your insurance company has paid us their portion, our Financial Advisors will process your patient portion to the credit card on file. Erindale Village Dental can provide estimates when requested. Receipts can be mailed or emailed to you.

 

Appointment Policy

Personal Data Protection

Dental records are collections of sensitive personal patient information compiled to allow dentists and other dental health care providers to offer dental treatment, maximize continuity of care, and maintain optimal standards of care. Original dental records compiled by a dentist are the legal property of the dentist.

Patients have a legal right to examine and copy their records and to control the use and dissemination of the information contained in their records. Dentists require patients to provide complete , accurate and intimate health details in order to provide safe and effective treatment. Therefore , owners hip of original dental records obligates the security and confidentiality of the information contained therein, which may be developed only with the permission of the patient except when otherwise required by law.

Patients have the right to control the disclosure of their dental records to others. Release of information must be informed ; must be specific and for a one-time event; must afford the patient an opportunity to review the information being requested and released prior to its transfer, and with the opportunity to withdraw prior consent; must not be used for any purpose other than the primary and specific use requested ; and must be done with the patient 's permission, preferably in writing.

Patients are entitled to receive dental care in a confidential selling free of third party intrusion . Release of patient information to third parties must adhere to the basic principles of confidentiality and patient rights outlined above with the intention of enabling patients to review any and all third-party benefits to which they may be entitled. Patients may be unaware of the information that third parties may have access to under broad-ba sed consents to release dental records , and the scope of this information may exceed the needs of a third party to determine benefits. It becomes the responsibility of the dentist and other dental health care providers to protect the confidentiality and privacy of their patients.

Where a third party (e.g., government agency, Canada Revenue Agency, dental association or insurance company) has received patient permission to use information from the patient's dental records for financial audits, all patient identity and unrelated information (e.g., health history, personal information) shall first be removed from the records. No third party can demand access to patient dental records (including financial records) except with specific patient consent in writing by legal statute or by court order.

 

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