Noonoo's Dentistry
1903 Ironoak Way, Oakville, ON L6H 0N1
289 837 0075
smile@noonoosdentistry.com
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COSMETIC & SMILE
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New Patients Form
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Dentist in Oakville Ontario
HOME
COSMETIC & SMILE
Veneers
Teeth Whitening
FAMILY DENTISTRY
Dental Restorations
Root Canal Treatment
Crowns Bridges
Children’s Dentistry
Dental Hygiene
Dental Implants
Emergency Dentistry
Wisdom Teeth Removal
Invisalign Clear Aligners
ABOUT US
Meet The Team
Gallery
Reviews
CONTACT US
New Patients Form
Blog
Dentist in Oakville Ontario
We'll make you smile
New Patients Form
First Name:
Last Name:
DATE OF BIRTH (D/M/Y):
DD slash MM slash YYYY
Age:
Gender
Male
Female
Phone (Home)
Phone (Cell)
Phone (Work)
Home Address:
City :
App/Unit
Province:
Postal Code:
Email
Occupation:
Employer:
Marital Status:
Single
Married
Common Law
Patients Under 18 years of age: Who is accompanying your child today?
Parents Names (Mother, Father Custody, Joint, Single (Mother / Father)
Name of Family Doctor:
Phone:
Address:
Name of your Specialist:
Phone:
Address:
In case of EMERGENCY, We should notify:
Name:
Relationship:
Phone:
How did you hear about us?
Google
Facebook
Instagram
Website
Flyer
Sign
Other
Referral: Friend (name)
Family (name)
Other (please specify)
*May we send you emails about important office notification, including appointment reminders? Yes No
Yes
No
Insurance Information
Primary Insurance Company Information
Name of Insurance Policy Holder:
Date of Birth:
DD slash MM slash YYYY
Policy holder Contact:
Contact Phone Number:
Group Policy/plan Number:
I.D./Certificate Number:
Marital Status:
Single
Married/Common Law
Other
Insurance Company Name:
Secondary Insurance Company Information
Name of Insurance Policy Holder:
Date of Birth:
DD slash MM slash YYYY
Policy holder Contact:
Phone Number:
Group Policy/plan Number:
I.D./Certificate Number:
Marital Status:
Single
Married/Common Law
Other
Insurance Company Name:
Medical History
The following information is required to enable us to provide you with the best possible dental care. All information in the medical and dental history is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Do you have or have you ever had any of the following:
Heart condition
Angina (Chest Pain)
Heart surgery/procedures
Heart attack
Stroke/T.I.A
Heart murmur
Mitral valve prolapse
Congenital heart disease
Infective Endocarditis
Pacemaker
High blood pressure
Low blood pressure
General Anesthetic complications
Diabetes: Type l or ll
Hypolglycemia
Rheumatic fever
HIV positive/AIDS
Leukemia
Anemia
Blood disorders
Hepatitis A/B/C
Hemophilia
Excessive bleeding/bruising
Immunedeficiencies
Eating disorder
Lupus
Thyroid disease
Kidney disease
Liver disease
HPV
Herpes/Cold sores
Physical impairment
Cancer
Asthma
Respiratory conditions
Lung disease
Tuberculosis
Snoring/sleep apnea
Dizziness/fainting
Ulcers/acid reflux
Intestinal/stomach problems
Above average weight gain/loss
COVID-19
Vision Impairment
Hearing impairment
TMJ (jaw joint) concerns
Arthritis
Joint Replacement
Osteoperosis
Epilepsy/seizures
Cognitive impairment
Depression
Anxiety
Mental health issues
Drug/alcohol dependency
Tobacco Use
Other
Are there any conditions or diseases not listed above that you have or have had?
Yes
No
Not Sure
If yes, Please explain
Do you have any allergies or sensitivities to any:
Medications:
Latex/rubber products:
Other: (e .g . hay fever, seasonal/environmental, foods):
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Yes
No
Not Sure
If yes, please list them:
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e., infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Yes
No
Not Sure
If yes, please explain:
Are you Pregnant?
Yes
No
Not Sure
If yes, what is the expected delivery date?
Are you breastfeeding?
Yes
No
Do you smoke or chew tobacco products?
Yes
No
Not Sure
To the best of my knowledge, the above information is correct.
Patient/Parent/Guardian Signature:
Date
DD slash MM slash YYYY
Dentist Notes:
Dentist Name:
Dentist Signature:
Date
DD slash MM slash YYYY
Dental History Questionnaire
1 . What is the reason for your visit today? Are you currently experiencing any dental problems?
2 . Have you been seeing a dentist regularly?
Yes
No
If not, why not?
3 . Are you nervous during dental visits?
Yes
No
4.1. When was your last dental visit?
4.2. What was done at that appointment?
5.1. How often do you brush your teeth?
5.2. How often do you floss?
6. Do your gums bleed when you brush or floss?
Yes
No
Not Sure
7 . Are you happy with the appearance of your teeth and your smile?
Yes
No
Not Sure
8 . Have you ever whitened your teeth?
Yes
No
8.1. No Are you interested in whitening?
Yes
No
9. Is there anything about the appearance of your teeth that you would like to change?
Yes
No
if yes please explain:
10 . Do you have any problems with your jaw (clicking, limited movement, pain)?
Yes
No
Not sure
Patient/Parent/Guardian Signature:
Date
DD slash MM slash YYYY
Dentist's Note:
Financial Policy
Our goal is to provide patients with highest dental care and transparency. Before proceeding with a treatment all fees and financial arrangements will be discussed with you and your questions will be answered. We take the time to ensure that you understand exactly what is being done, the costs, benefits and the risks. You will be asked to pay the fee at the time of service. You are responsible for the payment of all the fees for dental care rendered at Noonoo’s Dentistry. For your convenience if you would like we can contact your dental benefit provider so that you know what is covered. Since there is a possibility that the information given over the phone can be inaccurate, we cannot be accountable for what your benefits cover. We will submit the claim on your behalf and help you with any request your benefit provider might have. We Accept the following Payment methods; Cheque Cash Debit Credit Card
Appointment and Scheduling Policy
Lateness/ No Show / Cancellation Policy: A scheduled appointment means that the Dentist and the rest of the team have reserved a time specifically for you and no other patients are seen at that time. If you know you cannot make your appointment, we require 2 Business Days notice so that we can give your scheduled time to another patient. Patients who do not follow this policy for more than one time may be charged a fee and/or may no longer remain patients of this practice.
Privacy of Information Policy
Privacy of your personal health information is an important part of our office, providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Noonoo’s Dentistry is committed to respecting the privacy of individuals and recognizes a need for the appropriate management and protection of any personal information that you agree to provide to us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request. Privacy of your personal health information is an important part of our office, providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. We have outlined what our office is doing to insure the following: • Only necessary information is collected about Patients. • We only share your information with patient’s consent. • Storage, retention and destruction of your personal health information • complies with existing legislation, and privacy protection protocols. • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, And the law.
Patients Name
First
Last
Signature
hereby release and discharge Noonoo’s Dentistry and all persons functioning under his/her permission functioning under his/her permissions or authority from any legal or equitable claims including but not limited to the following: blurring of the image(s), alteration, distortion or use in composite form, libel invasion of privacy or any claims based on the production or in the process of recording or publishing the materials
Patients Name
First
Last
Signature
Photo Consent Form
I,
First
Last
hereby give Noonoo’s Dentistry, and any and all employees and/or agents of Noonoo’s Dentistry, the right and permission to use and/or publish photographs of me for art and promotions purposes including but not limited to, Advertising, publicity, commercial or display of use. Also authorize my photos to be posted on social media, such as Facebook Twitter and the office Facebook and Instagram Page.
Release of Claims.
I,
First
Last
hereby release and discharge Noonoo’s Dentistry and all persons functioning under his/her permission functioning under his/her permissions or authority from any legal or equitable claims including but not limited to the following: blurring of the image(s), alteration, distortion or use in composite form, libel invasion of privacy or any claims based on the production or in the process of recording or publishing the materials
Initial one of the following:
Yes, you may use my photos.
No, please do Not use my photo.
Name of Patient/ Parent / Guardian
First
Last
Patient/Parent/Guardian Signature: