New Patient Intake Form

Preferred Name:
Prefix First Middle Last
Gender
- Male
- Female
- Prefer not to disclose
Birth Date:
DD slash MM slash YYYY
Occupation:
Contact
Cell Phone
Home Phone
Work Phone
Email
We can communicate via phone, text or email. Please select all preferred contact methods
- Phone
- Text
- Email
Would you like to be contacted for short notice appointments?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact
Name Phone Relationship
How did you hear about us?
How did you hear about us?
- Online Search
- Facebook ad
- Billboard
- Drove by/saw sign
Professional (doctor, dentist, denturist, etc.)
Workplace
Community Event
Magazine/ Newspaper
Whom may we thank for referring you?
What office are you leaving?
What is your priority for your dental care?
Insurance (If applicable)
Primary:
Subscriber Name
Subscriber Birth Date
MM slash DD slash YYYY
Insurance Company
Policy Number
ID Number
Secondary:
Subscriber Name
Subscriber Birth Date
MM slash DD slash YYYY
Insurance Company
Policy Number
ID Number
Family Physician
Name
Address
Phone
PATIENT CONSENT: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of our office providing you with quality dental care. In this office, Dr. Dan Auprix acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us.

Attached to this consent form, we have outlined what our office is doing to ensure that: only necessary information is collected about you; we only share our information with your consent, storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; our privacy protocols comply with the privacy legislation standards of our regulatory body, the Royal College of Dental Surgeons of Ontario and the law.

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian Signature
Patient/Parent/Guardian Signature
Name of Patient/Parent/Guardian (print)

Name of Patient/Parent/Guardian (print)
Date
MM slash DD slash YYYY

Date
Phone
This field is for validation purposes and should be left unchanged.