Patient Intake Form – Dr Kevin J. McCann

Patient Information

The following information helps our office provide dental care that is safe and appropriate for your overall health. Some questions may seem unrelated to your dental or gum health, but they help us better understand and manage your oral health.

First Name(Required)

Last Name(Required)

Birth Date (D / M / Y)(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Canadian Resident?

Yes

Pharmacy Number

Home Phone

Business Phone

Cell Phone

Email Address(Required)

Emergency Contact

Relationship

Emergency Contact Number

Dentist

Dentist Phone

Medical History

1. Are you in good health?

Yes

2. Have you been under the care of a physician during the last 2 years?

Yes

Condition being treated

3. Date of last medical visit?

4. Have you had any serious illness or operation?

Yes

If yes, what

5. Have you been hospitalized within the last 5 years?

Yes

6. Circle any of the following which you have had or have at present:(Required)

7. Have you had abnormal bleeding with extractions, surgery, or trauma?

Yes

8. Are you allergic or have you reacted adversely to:

Local anaesthetics (Novocaine, Lidocaine, freezing, Latex)

Penicillin or other antibiotics (Sulfa drugs, etc.)

Barbiturates, sedatives, or sleeping pills

Advil or Tylenol (Ibuprofen or Acetaminophen)

Codeine or other narcotics

Latex

Other

Other allergy details

9. Are you taking any drug or medication?

Yes

If yes, what are you taking? Please list the names and dosages.

10. Do you smoke or vape?

Yes

If yes, how many a day?

Do you drink alcoholic beverages?

Yes

If yes, how many a week?

Do you use recreational drugs?

Yes

11. Have you had in the past or do you presently have any disease, condition, or problem not listed above?

Yes

12. Has anyone in your family had diabetes?

Yes

13. Women: Are you pregnant?

Yes

If yes, what trimester are you in?

13.2 Are you taking birth control?

Yes

14. Problems of the jaw. Have you ever experienced:

Clicking of the jaw

Pain (joint, ear, side of face)

Difficulty in opening and closing or chewing

15. Habits. Do you:

Clench or grind your teeth while awake or asleep

Bite your lips or cheeks regularly

Hold foreign objects with the teeth (such as pencils, pipe, nails, fingernails)

Mouth breathe while awake or asleep

Dental History

1. Are you having any discomfort at this time?

Yes

5. Do you clench or grind your teeth?

Yes

8. Problems of the jaw. Have you experienced:

Clicking of the jaw

Pain joint, ear, side of face?

Difficulty in opening

9. Have you had any serious trouble with any previous dental treatment?

Yes

Please specify

10. Are you tense during dental visits?

Yes

14. How often do you floss your teeth?

Privacy Statement, Insurance, and Signatures

PRIVACY STATEMENT

A. I have read and understand the PRIVACY STATEMENT FOR PATIENTS.

B. I consent to the collection, use, and disclosure of my personal information as presented in the statement.

I, the undersigned, certify that all the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I understand that it is my responsibility to inform this office of any change in my medical status.

Privacy consent(Required)

I have read and understand the privacy statement and consent to the collection, use, and disclosure of my personal information.

Patient Signature (Guardian’s Signature if patient is under 18)(Required)

Date(Required)

A. I authorize the release, to my dental benefits plan administrator and the CDA, of information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services to Dr Kevin J. McCann.

B. I hereby assign my benefits, payable from claims submitted electronically, on my behalf to Smiles First Corption.

C. This authorization shall continue in effect until the undersigned revokes it.

Patient Signature (Guardian’s Signature if patient is under 18)(Required)

Date(Required)

Office Policy

1. Please remember that once you have made an appointment, this time is reserved for you. At least 2 business days prior notice must be given if cancellation is absolutely necessary.

2. Office policy is that services are paid for at each visit by the patient or through direct billing if dental insurance is applicable.

3. Regarding insurance: We offer direct billing to insurance providers whenever possible. Please note that insurance coverage is not guaranteed, and patients are ultimately responsible for any unpaid balances or charges on their account.

Dr Kevin J. McCann Privacy Statement

Privacy of our patient’s personal information is important to us. We are committed to collecting, using and disclosing personal information responsibly.

Personal Information
Personal information for our purposes is that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes all that information provided by you to us on our patient information/health/medical history form at the first visit and any subsequent visits. Personal information may also include any information provided by you to us during the normal course of communication between patient and dental office staff. We will use and disclose only information provided to us by you or another person acting on your behalf.

Information Protection
We are committed to protecting your personal information. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft and unauthorized access. Access to your personal information shall be on a “need to know” basis.

Information Disclosure
Your personal information shall be disclosed to only those who have a need to know and the specific information disclosed shall be restricted to only that information relevant to the recipients’ need to know. Those who have a need to know include other dentists and health care providers, dental specialists, personal physicians, dental lab. Further, the personal information disclosed to dental benefit providers is limited to only that personal information required by the provider. You may at any time designate any restrictions as to whom we may disclose your personal information or restrict the content of a disclosure.

Information Retention and Destruction
We will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with Provincial or Federal regulations or statutes.

Your Access to Your Records
We are committed to providing you with open access to your personal information held by us. You may at any time ask us to see your records held by us and to request amendments to that information. We will provide access to you within a reasonable time-frame recognizing your desire for the information and our need to carry on our practice with limited interruption.