Please fill out the mandated COVID-19 Screening Form below before your next appointment.


Are you a current or new patient?*
Patient Name*
Question 1: Are you immunocompromised and/or live in a highest-risk congregate care setting?*
Question 2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.*
Question 3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other goverment authority) that you should currently be quarantining, isolating or staying at home?*
Question 4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?*
MM slash DD slash YYYY


Privacy of Personal Information

(for collection, use and disclosure of personal information)

Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is very important to us to provide this service to all of our patients.

In this dental office, the Office Manager 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. They are all trained in the appropriate uses and protection of your information. Here is an outlined policy that our office follows to ensure you that:

  • Only the necessary information is collected from you.
  • We only share your information with your consent.
  • Storage, retention, and proper destruction of your personal information complies with the 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.

Do not hesitate to discuss our policies with any member of our office staff.

Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

How Our Office Collects, Uses and Discloses Patient’s Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. Our office will collect, use and disclose information about you for the following purposes to:

  • deliver safe and efficient patient care.
  • identify and to ensure continuous high-quality service.
  • access your health needs.
  • advise you of treatment options.
  • establish and maintain communication with you.
  • enable us to contact you.
  • offer and provide treatment, care and services in relation to the oral and dental care.
  • communicate with other treating health care providers, including specialists and general dentists who are referring dentists and/or peripheral dentists.
  • allow us to maintain communication and contact with you to distribute healthcare information and to book, and confirm appointments.
  • allow us to efficiently followup for treatment, care, and billing
  • teaching and demonstrating purposes on an anonymous basis.
  • complete and submit dental claims, and estimates for third-party adjudication and payment.
  • comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act.
  • comply with agreements/undertakings entered into voluntary by the member with the patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes.
  • prepare materials for the Health Professions Appeal and Review Board (HPARB). invoice for goods and services.
  • process credit card payments.
  • collect unpaid accounts.
  • assist this office to comply with all regulatory requirements.
  • comply generally with the law.


Name of Guardian*
Patient Name
MM slash DD slash YYYY
By signing the consent section of this patient consent form, you agree 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 defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.
Use your mouse or finger to draw your signature above.
MM slash DD slash YYYY


Patients Name
MM slash DD slash YYYY
MM slash DD slash YYYY
Parent Name
Please check any of the following that apply:

Has your child ever had any of the following?


Does your child have or have they ever had any of the following?

Please check any of the following that apply:

For Parents

Dental Insurance

Parent Name ( required for under 18 years )
Use your mouse or finger to draw your signature above


Periodontist Referral
Reason for periodontist referral:
IV Sedation Referral
Reason for IV sedation referral:
Orthodontist Referral
Reason for orthodontist referral:
We are introducing:
MM slash DD slash YYYY
Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.
Indicate any special factors –either dental or medical –such as allergies and medical problems relevant to diagnosis and treatment.
Digital Radiographs*
Select all that applies
MM slash DD slash YYYY