Below are 2 separate forms. Please read the patient acknowledgement below, and check mark/fill in all areas indicated prior to your appointment. Name * First Name Last Name Date * MM DD YYYY I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to and avoid close contact with other people when at all possible. * I Understand I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental hygiene treatment. I understand that due to the visits of other patients, going to other patients households, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus Please check the box to confirm all of the above: * I Understand I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache. I confirm that I have not tested positive for COVID-19. I confirm that I am not waiting for the results of a test for COVID-19. I confirm that this is not currently a period where I required to self-isolate for 14 days. Please check the box to confirm all of the above: * I Understand * I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental hygiene treatment completed during the COVID-19 pandemic. Please fill out your full name again and include your email (for confirmation purposes and to send a copy to you if you require): First Name Last Name Email * Thank you! COVID Form Name of patient * First Name Last Name Preferred name to be called Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * I will be arriving at a * House Apartment Townhouse Office Nursing Home Please Park: * Driveway Road Visitors Parking Other Date of Birth * Age * What is the reason for this dental visit? Insurance Information Secondary Insurance: Medical Information Health History: Are you being treated for any medical condition: Yes No I was, but not currently If YES, for what? List all the medications you're taking (or write NONE): List DOSAGE of all medications please (or write NONE): Do you have any allergies? Do you smoke or use any other forms? Indicate below any conditions you have or have had (indicate all that apply please): Chest pain Heart attack Stroke High or Low blood pressure Pacemaker Lung disease Cancer Tuberculosis Diabetes Hepatitis Kidney disease Arthritis Thyroid disease Anemia Drug or Alcohol dependency Rheumatic fever Sinus problems Anxiety and/or Depression Herbal therapy HIV Please explain your conditions further: Any conditions not listed: Do you have any family history of diabetes, heart conditions, or other? Please include: What is your diet like? Coffee? Tea? Sugar? Soda? Please list: Dental History Are your teeth sensitive? Yes - to cold Yes - to hot Yes - when eating No Helpful Information For your dental hygiene visit - you would prefer: Lots of communication Minimal communication Doesn't matter Are you in a wheelchair: Yes No Other If OTHER, please list any special accommodations required: Do you have any dental phobias? Please explain (sound, financial burden, dental anxiety, etc) Any additional comments you would like to add: You understand that this information will be used by LG Mobile Dental Hygiene and you consent that the above is correct. (check mark the YES box below): * Yes Full name of person filling out this form: * General Release Form I, the undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive any questions regarding my medical – dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental hygienist. I authorize the provider to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from, or to, my medical doctor or another health provider may be necessary. This office has a privacy policy that protects my personal information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. Yes, I consent No, I do not consent Authorization and Release I certify that I have read and understand the above questions to the best of my knowledge and the above questions have been accurately answered. I understand that providing incorrect or withholding information can be dangerous to my health. I authorize the Dental Hygienist to release any information including the Dental Hygiene diagnosis and the records of any treatment or examination rendered to the named client during the period of such Dental Hygiene care to third party payers and/or health practitioners for insurance and health-related referral purposes only. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize payment directly to Lynette Gordon, RDH with LG Mobile Dental Hygiene Services from any group insurance benefits otherwise payable to me. I understand my personal information is collected, used, and stored in a professional and responsible manner according to PIPEDA/PHIPA standards and LG Mobile Dental Hygiene Services privacy policy. My dental hygiene services are rendered according to the standards of infection control mandated by the CDHO. I understand that payment is due in full after treatment is rendered (unless prior arrangements have been approved). I give consent for dental hygiene treatment on my behalf (or my dependent) and understand that the specific risks, benefits, and post care instructions will be provided by the dental hygienist during the relevant course of the appointment. Additional written informed consent may be required for complicated or special procedures. I understand that any questions I may have regarding any treatment should be brought forth to be answered and addressed by the dental hygienist. Check the box below if you agree to the above terms under Authorization and Release: Yes, I consent No, I do not consent Thank you! New Patient Intake FormsAll new patients - please fill out the form below and click submit to send
