First Name:

Last Name:

DATE OF BIRTH (D/M/Y):

Age:

Gender

Male

Female

Phone (Home)

Phone (Cell)

Phone (Work)

Home Address:

City :

App/Unit

Province:

Postal Code:

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

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

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:

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:

Other

Are there any conditions or diseases not listed above that you have or have had?

Yes

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

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

Not Sure

If yes, please explain:

Are you Pregnant?

Yes

Not Sure

If yes, what is the expected delivery date?

Are you breastfeeding?

Yes

Do you smoke or chew tobacco products?

Yes

Not Sure

To the best of my knowledge, the above information is correct.

Patient/Parent/Guardian Signature:

Date

Dentist Notes:

Dentist Name:

Dentist Signature:

Date

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

If not, why not?

3 . Are you nervous during dental visits?

Yes

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

Not Sure

7 . Are you happy with the appearance of your teeth and your smile?

Yes

Not Sure

8 . Have you ever whitened your teeth?

Yes

8.1. No Are you interested in whitening?

Yes

9. Is there anything about the appearance of your teeth that you would like to change?

Yes

if yes please explain:

10 . Do you have any problems with your jaw (clicking, limited movement, pain)?

Yes

Not sure

Patient/Parent/Guardian Signature:

Date

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

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.

First Last

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:

We'll make you smile

We'll make you smile

New Patients Form

Insurance Information

Medical History

Dental History Questionnaire

Photo Consent Form

Release of Claims.