Step 1 of 5 - About You20%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.First Name(Required)Middle Initials (optional)Last Name(Required)Preferred Name (optional)Address(Required) Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Gender(Required) Male Female OtherProvide at least one phone number to contact you at: (Required)Mobile PhoneHome PhoneWork PhoneCan be best contacted at(Required) Mobile Phone Home Phone Work PhoneBest time to call? (optional)Email Address(Required) Enter Email Confirm Email Emergency Contact Name(Required)Emergency Contact Phone Number(Required)How did you hear about us?(Required) Google Facebook Website Friend or Family Other How would you rate your dental health?(Required) Poor Average ExcellentWhat dental condition concerns you at present? (optional)When was your last visit to the dentist?(Required)When was your last cleaning?(Required)Do you have sore, aching or sensitive teeth?(Required) Yes NoDo your gums ever bleed?(Required) Yes NoDo you have pain or discomfort elsewhere on your face or jaw (TMJ)?(Required) Yes NoDo you have any loose teeth?(Required) Yes NoDo you grind or clench your jaw or teeth during the day or at night?(Required) Yes NoDoes food catch frequently between any of your teeth?(Required) Yes NoAre you happy with the way your smile looks?(Required) Yes NoWould you like whiter teeth?(Required) Yes NoIs snoring a problem for you?(Required) Yes NoIs there anything else the Doctor should know about you?(Required) Yes NoIf yes please list:(Required) Are you under the care of a physician?(Required) Yes NoIf yes, please explain:(Required)Your Physician's Name (optional)Your Physician's Phone Number (optional)Have you had a major operation?(Required) Yes NoIf yes, please describe:(Required)Do you have any health problems that need further clarification?(Required) Yes NoIf yes, please explain:(Required)Have you ever had any complications following dental treatment?(Required) Yes NoIf yes, please describe:(Required)Do you currently or in the past had any of the following?Select all conditions that apply to you. Anemia Angina Arthritis Artificial Bones/Joints Artificial Heart Valve Asthma Blood Disorder Cancer Congenital Heart Defect Diabetes Emphysema Epilepsy/Seizures Frequent Headaches Glaucoma Hay Fever Head Injuries Heart Attack Heart Murmur Hemophilia Hepatitis A/B/C High or Low Blood Pressure HIV/AIDS Joint Replacement Kidney Disease Liver Disease Lung Disease/Tuberculosis Mental Disorder Mitral Valve Prolapse Pacemaker Radiation Rheumatic Fever Sinus Problem STD Stomach/Intestinal Problems Stroke Thyroid Disease Tumors UlcersI confirm that I currently have or had in the past the selected conditions:(Required) ConfirmI confirm that I do not have and never in the past had any of the above conditions:(Required) ConfirmAre there any other serious medical conditions you have or had in the past?(Required) Yes NoPlease list any other serious medical conditions you have or had in the past:(Required)Are you currently taking any medications?(Required) Yes NoPlease list any current medication you are taking:(Required)Do you require pre-medications prior to dental treatment?(Required) Yes NoAre you Allergic to any of the following?Select all allergies that apply to you. Aspirin Codeine Dental Anesthetic Erythromycin Keflex Latex Local Anesthetic Metals Penicillin Sedatives Sulfa Drugs TetracyclineI confirm that I am allergic to the selected items:(Required) ConfirmI confirm that I am not allergic to any of the above listed items:(Required) ConfirmDo you have any other allergies?(Required) Yes NoPlease list your other allergies:(Required)For women:Are you taking Birth Control Pills?(Required) Yes NoAre you Pregnant?(Required) Yes NoAre you Nursing?(Required) Yes NoHave you ever had any complications with local anesthetic (freezing)?(Required) Yes NoHave you ever had complications with nitrous oxide?(Required) Yes No Do you have dental insurance?(Required) Yes NoPlease initial each box to indicate you have read these policies.Due to the recent legislation, you are covered under the privacy act; your information through your insurance provider is confidential and will not be released to our office. Therefore, we urge you to become familiar with any dental benefits you may have. Ultimately if there is a problem with your insurance, it is your responsibility.Initial here:(Required)Full payment is due at time of treatment.Initial here:(Required)Two Payment options are available - Please choose ONE onlyOption 1 (Non-Assignment)All accounts are paid at the time of service. The cheque is mailed by your insurance company, made payable to the subscriber and you may receive it in as little as 3 days.Option 2 (Assignment)In order for Creekside Dental Care to accept payment from your insurance, our office requires the following:Any portion not covered by insurance must be paid at time of serviceValid Alberta Drivers LicenceAll accounts to be cleared within 45 days from treatment date otherwise a 15% interest charge will incurBy choosing Option 2 (Assignment), you will be asked to provide the above required information at your first dental appointment.Are you selecting Option 1 (Non-Assignment) or Option 2 (Assignment)?(Required) Option 1 (Non-Assignment) Option 2 (Assignment)Please initial here to confirm you have selected Option 1 (Non-Assignment):(Required)Please initial here to confirm you have selected Option 2 (Assignment):(Required)The insurance claim will be sent electronically. If Insurance does not provide the exact patient portion, our office will estimate your portion for the visit. Should the charge be over $200.00, our office will try to contact you prior to putting the charge through, however we are not calling for authorization but rather to make you aware of the charge. We wish to stress that the financial responsibility for services rendered rests with the patient and his/her family, regardless of any insurance coverage; your insurance policy is a contract between you and your insurance company. We cannot guarantee payment or coverage of your claim.In the rare case that we have not received the insurance payment within 31 days, we will then contact yourself so that you may contact your insurance company to enquire about the claim. If within 45 days of your treatment our office has still not been paid, we will then inform you that your credit card will be charged the total amount owing. All collection costs will be paid for by the patient.Initial here:(Required)I agree to pay all fees and charges for services rendered for myself and my family. I agree to pay all charges when presented with a statement, unless prior credit arrangements are agreed upon in writing. I understand and agree, regardless of my insurance status, I am ultimately responsible for any unpaid balance on my account.Initial here:(Required)We reserve the right to submit your account to a third-party collection agency in the event of any outstanding balance owing over 90 days. This includes the right to share any relevant personal / contact information that has been provided to Creekside Dental Care.Initial here:(Required)If you require pre-authorization, it is the responsibility of the patient to request our office to complete one on your behalf. Our office will only complete one on your behalf once the corresponding appointment is booked due to the amount of time and work that goes into each pre-authorization. Once the pre-authorization has been assessed by your insurance, it will then be forwarded to the policy holder. Our office will not receive a copy unless it is provided to us by the patient. Please either email, fax or drop off a copy to our office so that we may assess the accuracy of the pre-authorization. At that time, we would be more than happy to complete a breakdown of your coverage so that you are aware of your estimated payment from insurance.Initial here:(Required)We do our best to respect our patient's time and in turn ask for the same courtesy. Therefore, our office requires 48 hours notice to change a scheduled appointment. If we are not provided such notice or an appointment is missed a $50.00 and up fee will be charged. This fee must be paid prior to any further appointments.Initial here:(Required) To the best of my knowledge, all of the preceding information I have provided is true and correct. If I ever have a change in my health, or a change in my dental coverage, I will inform the office at my next dental appointment without fail.I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependant(s) to third-party insurance carriers, payers, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance (if applicable), and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).Thank you for choosing Creekside Dental Care, we look forward to taking care of your dental health.If you have any questions regarding this agreement, please do not hesitate to bring it to our attention.Please initial here:(Required)PhoneThis field is for validation purposes and should be left unchanged.