Emergency Medical History

MEDICAL ALERT:*

Patient Name:* Date of Birth:*

Gender:*

Male Female Prefer not to disclose

Home Address:*

Home Phone:* Cell:

Email:

Occupation:* Allergies (Hay fever, seasonal, food):* Allergies to medications:*

Any allergies to following medications?

Family Physician Name and Phone:*

Emergency contact:

Name:* Phone:*

Relationship to patient:*

Please check mark any of the following that apply past or present:

Please list any medications you are presently taking:

Previous Dental Clinic: Previous Dental Clinic Number:

Toothache/Tooth Injury:

Please rate the level of pain you are experiencing on a scale of 1-10

(1 being minimal and 10 extreme)*

Are you experiencing any of the following symptoms?

Are you experiencing any sensitivity?

Yes No

If yes, please advise Hot, Cold or Both

Hot Cold Both

How long ago did the injury occur:* Where did the injury occur:* Describe in your own words what happened:*

Is there any Lips/soft tissue bleeding, cuts, ulcerations, bruising

Yes No

(If bleeding occurred outside, it is advised to have a tetanus booster if you're not up-to-date on your vaccination)

If yes, please indicate which:

Is there any teeth movement, displacement, fracture, bleeding or discoloration?

Yes No

If yes, please indicate which:

If your tooth broke, do you have the missing piece?

Yes No

If your tooth got knocked out (avulsed), please see attached link to OPH

https://www.ottawapublichealth.ca/en/public-health-topics/resources/Documents/tooth_injury_en.pdf

Dental Insurance Information

Primary Insured's Name:* Date of Birth:* Insurance Company:*

Group #:* Policy #:*

Relationship to subscriber:*

Do you have dual coverage? If yes, list below

Secondary Insured's Name: Date of Birth:* Insurance Company:*

Group #:* Policy #:*

Relationship to subscriber:*

I give my consent for the dentist of this office to do an emergency dental examination on the patient listed above. X-rays that are necessary to properly complete the exam may be taken. I will be informed of any additional treatment that may be required and it will be fully explained to me prior to commencing. I agree to inform the doctors of any changes in my medical information and I authorize the release of any information relating to any dental claims. By signing this, I agree that the medical history is filled out to the best of my knowledge and I accept financial responsibility.

PATIENT CONSENT: The privacy of your personal information is a priority in our commitment to providing high-quality dental care. We recognize the importance of safeguarding your personal data and are dedicated to handling it responsibly, ensuring its collection, use, and disclosure are managed with the utmost care. All staff members who have access to your personal information are thoroughly trained in its proper handling and protection. In this consent form, we have detailed the measures our office takes to ensure that:

Only the necessary information is collected from you.
Your information is shared exclusively with your consent.
The storage, retention, and destruction of your personal information adhere to applicable legislation and privacy protocols.
Our privacy practices are fully compliant with the privacy standards set forth by our regulatory body, the Royal College of Dental Surgeons of Ontario, as well as relevant laws.

This office will collect, use and disclose information about you for the following purposes:

To provide safe and efficient patient care.
To ensure continuous high-quality service.
To assess your health needs.
To deliver appropriate healthcare services.
To inform you of available treatment options.
To facilitate communication, including scheduling and confirming appointments, follow-ups, and billing matters.
To offer and provide treatment and care related to the oral and maxillofacial complex and general dental care.
To communicate with other healthcare providers, including specialists and referring or peripheral dentists.
To submit dental claims for third-party adjudication and payment.
To meet legal and regulatory obligations, including providing patient records to the Royal College of Dental Surgeons of Ontario as required by the Regulated Health Professions Act.
To deliver patient charts and records to the dentist’s insurance carrier for liability assessment and damage quantification, if applicable.
To prepare documentation for the Health Professions Appeal and Review Board (HPARB).
To allow potential purchasers, practice brokers, or advisors to assess the practice or conduct an audit in preparation for a practice sale.
To invoice for goods and services.
To process credit card payments.
To collect outstanding accounts.
To ensure compliance with regulatory requirements.
To comply with applicable laws and regulations.

By signing this consent section of the Patient Consent Form, you acknowledge that you have provided informed consent for the collection, use, and/or disclosure of your personal information for the purposes outlined. Should a new purpose arise, we will seek your approval in advance.

Your information may be accessed by regulatory authorities by the Regulated Health Professions Act (RHPA) to enable the Royal College of Dental Surgeons of Ontario to fulfill its mandate under the RHPA, as well as for the defence of any legal matters.

Under no circumstances will our office provide your insurer with your confidential medical history. If such a request is made, we will promptly forward the information to you for review and obtain your explicit consent before any disclosure.

When we receive unusual requests for your information, we will contact you to obtain your permission before releasing any data. Additionally, we may inform you if we believe that such a release would be inappropriate. You have the right to withdraw your consent for the use or disclosure of your personal health information at any time.

PATIENT CONSENT: I have reviewed the information provided above, which outlines how your office will use my personal information and the measures being taken to protect it. I consent to Gumtree Dental Care collecting, using, and disclosing my personal information to the following individual(s).

Please Sign Below:* Write your signature below.

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