Copperstonedental.ca

Confidential Patient Record
Patient: Mr. / Mrs. / Miss______________________________________________________________________________________ Date of Birth: ________________________ Emergency Contact Name: __________________ Phone #:____________________ Address: _______________________________________________________ Marital Status: Married Single Postal Code: __________________ Email: ___________________________
Work #: ____________________ Cell #: ___________________________ Occupation: ________________________ Employer: ______________________ (please circle)
Friend/Family Referral (name) ______________________________________ Do you have Dental Insurance Coverage? Yes No If yes, please provide us with benefits card for direct bil ing Medical History
1. Are you currently in good health? Yes _______________________________________________________________________________ 2. Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)? Yes If yes, please list_______________________________________________________________________________________ 4. Are you allergic to or ever had a reaction to any of the following: (please circle)
5. Are you under the regular care of a physician If yes, Please explain ___________________________________________________________________________________ 6. Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal? Yes No 7. Have you ever had a serious il ness or operation? 8. Do you currently have or ever had any of the fol owing conditions? (please circle)
No If yes, which trimester? ______________________________________ 9. Is there anything else we should know about your health? Yes No If so, please explain__________________________ Dental History
1. What dental condition(s) concern you at present? _________________________________________________________ 2. When was your last dental check-up and cleaning? _________________________________________________________ 3. Were X-rays taken at your last dental visit? 4. When was the last time you changed Dental Offices _________________________________________________________ 5. Have you noticed any signs of the fol owing? (please circle)
Bleeding gums Swel ing of Gums Gum Ache Receding Gums Loose Teeth Drifting of Teeth 6. Do you have any clicking, popping or pain in your jaw joint? 7. Are you aware of clenching or grinding your teeth? 8. Do you have any missing teeth that you feel should be replaced? 9. Would you like to improve the appearance of your teeth? 11. Have you had any complications or difficulty with previous dental treatment? 12. How do you rate yourself as a dental patient? I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I wil assume responsibility for fees associated with those procedures. Date_____________________________________________ Signature ________________________________________________________ Office Policies
Copperstone Dental complies with the Alberta Personal Information Act (PIPA) and the Health Professions Act in regards to the management, col ection, destruction, use and disclosure of our patient’s personal dental/medical
Cancel ation Policy
Due to a continuous high demand in prime appointment times, we require a minimum of 2 business days advance
notice should you require to reschedule your appointment. This is valuable time that the Doctor and staff have reserved specifical y for you. In the case that insufficient notice is given or you fail to attend your appointment on multiple occasions, we wil not be able to schedule and reserve future appointment times for you.
Direct Billing
Due to the Canadian Personal Privacy Act, we are unable to access any sufficient information from your insurance company regarding your dental plan. It is your responsibility to know the details involved in your plan such as
annual maximums, frequencies, and any other limitations. We extend the courtesy to bil your insurance directly,
however to avoid any patient portion discrepancies, please be ful y aware of the particulars of your plan so you can utilize your benefits to their maximum. Copperstone Dental can also provide estimates when requested so you

Copperstone Dental is pleased to offer you the fol owing payment options. Please CIRCLE which option you would

Option A:
Payment is due in full the day of treatment is rendered. We accept Cash, Visa, Debit, MasterCard, and American Express. Copperstone Dental wil process your payment on the date treatment is
rendered. Our treatment coordinator wil assist you in submitting the necessary documents to your insurance carrier and the insurance cheque wil be sent directly to you, the patient. You wil be required to leave your credit card number on file and we wil direct bil your insurance company. Any outstanding amounts wil be applied to your credit card on file once your insurance company has paid us their portion.
If we receive an explanation of covered costs from your insurance company at the time of your visit, you wil be
required to pay the outstanding balance before you leave.
Please sign below acknowledging that you have read and understand the office polices at Copperstone Dental.
Signature: ________________________________________
For Option B only:
I, _________________________________________ have chosen Option Two, and herby authorize
any balances outstanding which is not covered by my dental insurance to be automatical y applied to:
Credit Card (circle one):
Card Number: ________-________-________-________ Expiry Date :____________( mm/yyyy)
Name (as it appears on card):____________________________________
Signature of Cardholder:________________________________________
Receipts wil be emailed to the fol owing address:
Email: ________________________
(if requested)

Source: http://www.copperstonedental.ca/pdf/copperstone-new-patient-forms.pdf