Medical History
1. Have you been under the care of a medical doctor during the past two years?
2. Have you taken any medication or drugs (prescription, recreational, or supplements) now or during the past two years?
3. Are you aware of having an allergic (or adverse) reaction to any medication or substance?
4. Have you been hospitalized in the past five years?
5. Do you smoke or chew tobacco?
6. Do you have / wear a snore guard, CPAP machine, or nightguard?
Personal Information Consent
(905) 595-2522 · info@duodental.com
We are committed to protecting the privacy of our patients' personal information and to using it in a responsible and professional manner. This form summarizes the personal information we collect, use, and disclose. We also collect, use, and disclose personal information when permitted or required by law, beyond what is described here.
We collect information such as names, home and work addresses, home and work phone numbers, and email addresses (referred to as "Contact Information").
How we use Contact Information
- To open and update patient files
- To invoice patients for dental services, process credit card payments, or collect unpaid accounts
- To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
- To send reminders concerning further dental examination or treatment
- To send informational material about our practice
Contact Information is disclosed to third-party health benefit providers and insurance companies when a patient submits a claim for reimbursement, or asks us to submit a claim on their behalf. Financial information may be collected to arrange payment for dental services.
We also collect health history, family health history, physical condition, and dental treatment details (referred to as "Medical Information"), used to diagnose dental conditions and provide treatment.
How Medical Information is disclosed
- To third-party health benefit providers and insurance companies for claims submitted by or on behalf of the patient
- To other dentists and dental specialists for a second opinion, with patient consent
- To other dentists and dental specialists when a patient is referred to them for treatment
- To other dentists and dental specialists who request a second opinion, with patient consent
- To other health care professionals, such as physicians, when a patient is referred for a second opinion or treatment
If we ever consider selling all or part of our practice, qualified potential purchasers may be granted access to patient information during due diligence to verify details relevant to the sale. We take steps to ensure any prospective purchaser safeguards that information. Dentists are regulated by their Dental Association and College, which may inspect our records as part of regulatory activity in the public interest.
Cancellations & missed appointments
When you book an appointment with us, we reserve that time specifically for you to see the dentist or hygienist. We require 48 hours notice if an appointment must be cancelled, so the time can be offered to another patient awaiting treatment.
Short-notice cancellations (less than 48 hours) and missed appointments are subject to a $50.00 fee.
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