249 Danforth Avenue, Toronto, ON, M4K 1N2

CONFIDENTIAL INFORMATION QUESTIONNAIRE

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GENERAL INFORMATION

Patient’s First Name:
Patient’s Middle Name:
Patient’s Last Name:
Preferred Name:
Patient is a(n):	AdultChildAdult Under Guardianship
Birth Date (yyyy/mm/dd):
Gender:	MF
Guardian’s Name::

CONTACT INFORMATION

Address:
Apt #:
City:
Province:
Postal Code:
Home #:
Work #:
Cell #:
Other #:
Ok to call work?:	YesNo

ADDITIONAL INFORMATION

Marital Status:
Patient’s/Guardian’s Employer:
Occupation:
Reason for today’s visit?:
Dental problem for immediate treatment?:
Emergency Contact:
Relationship:
Work #:
Home #:
Other family members that are patients here:
Who may we thank for the referral?:

INSURANCE AND FINANCIAL INFORMATION

Person responsible for account:	SelfSpousePartnerOther
Name:
Home #:
Work #:
Employer:
Insurance Coverage:	YesNo
Patient’s Relationship to Subscriber:	SelfSpousePartnerOtherDependent
Subscriber’s Name:
Birth Date (yyyy/mm/dd):
Insurance Company:
Employer:
Group/Policy #:
Division #:
Certificate/ID #:
Secondary Insurance:	YesNo
Patient’s Relationship to Subscriber:	SelfSpousePartnerDependent
Subscriber’s Name:
Birth Date (yyyy/mm/dd):
Insurance Company:
Employer:
Group/Policy #:
Division #:
Certificate/ID #:
Method of Payment:	CashDirect PaymentCredit CardOther

RELEASE

I am financially responsible for any balances due on the day of treatment, and authorize the dentist to release any information for insurance claims to the insurance company on my behalf. In consideration of the services rendered to me by this office I am obligated to pay said office in accordance with its credit terms and policy. I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

I also authorize the dentist to use my email and or cell phone number to confirm/re-schedule appointments, send enewsletters or any vital electronic information that may help me keep informed about my oral health. I understand that I can unsubscribe at any time.

I have read and agree to the above release: Yes