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Contact form Name First Last Email PhoneMessage DENTIST REFERRAL Periodontist Referral Dr. Sherif Said Dr. Freddy Fokum Reason for periodontist referral: Periodontal Disease/Gum Pockets Gum Recession/Gingival Graft Crown-Lengthening Biopsy Implants Oral Surgery Other Other IV Sedation Referral Dr. Kirsty Large Reason for IV sedation referral: Extractions Crown & Bridge General Restorative Periodontal Care Endodontic Therapy Implants Orthodontist Referral Dr. Ahmed Rizk Reason for orthodontist referral: Invisalign Crowding Spacing Crossbite(s) ( Anterior, Posterior ) Mixed dentitional consideration ( serial extractions, space maintenance ) Other/specific problem We are introducing: First Last Date of Birth MM slash DD slash YYYY Email PhoneAppointment* Patient has an appointment Patient to call for an appointment Please call patient for an appointment CommentsPlease provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.Relevant HistoryIndicate any special factors –either dental or medical –such as allergies and medical problems relevant to diagnosis and treatment.Digital Radiographs* Attached Patient to Bring No Radiographs Radiographs Panoramic Bitewing Periapical Select all that appliesReferring Clinic Name Referring Dentist Name:* Referring Dentist Phone Number* Referring Dentist Email* Date of Referral MM slash DD slash YYYY Oops! 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Contact form 1 Name* Email* Subject* Your Message (optional) UPDATED MEDICAL HISTORY Patient Type* Adult Child Adult Under Guardianship Email* Self Identification* Man Woman Other Non-Binary Name of Patient* First Last Date of Birth MM slash DD slash YYYY Address* Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code Primary Contact Number* Home Phone Work Phone Best number to reach you at?* Home Primary Contact Number Work Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Explain further DetailsWhen was your last medical checkup?* Has there been any change in your general health in the past year?* Yes No Please Explain further DetailsAre you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Explain further DetailsDo you have any allergies?* Yes No Please list allergies belowHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Explain further DetailsDo you have or have you ever had asthma?* Yes No Please Explain further DetailsDo you have or have you ever had any heart or blood pressure problems? Yes No Please Explain further DetailsDo 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 No Please Explain further DetailsDo you have a prosthetic or artificial joint?* Yes No Please Explain further DetailsDo you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Explain further DetailsHave you ever had hepatitis, jaundice or liver disease?* Yes No Please Explain further DetailsHave you ever been hospitalized for any illnesses or operations?* Yes No Please Explain further DetailsDo you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) loss of hearing difficulty hearing None of above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Explain further DetailsDo you smoke or use other nicotine products? Yes No Are you breastfeeding or pregnant?* Yes No If pregnant, what is the expected delivery date? MM slash DD slash YYYY Do you have a disability or are a person with visual impairment* Yes No Please Explain further DetailsGeneral Release I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this 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. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature aboveDate MM slash DD slash YYYY NEW PATIENT FORM How did you hear about us?*SelectPatient ReferralLives in AreaWorks in BuildingRadioSocial MediaOtherGive some Details:Are you a new or current patient?* New Patient Current Patient Other Patient Contact Information Patient Type*AdultChildAdult Under GuardianshipName of Guardian First Last Gender* Male Female Other Name of Patient* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City* Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code* Country*Select countryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombia" "ComorosCongoCongo, The Democratic Republic of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-bissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenEswatiniSwedenSwitzerlandSyrian Arab RepublicTaiwan (ROC)TajikistanTanzania, United Republic ofThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweEmail* Home Phone NumberCell Phone NumberWork Phone Number Best way to contact you:* Cell Home Work Family Physician Specialist Name Emergency Contact Emergency Contact Phone NumberInsurance InformationPrimary Insurance CompanyInsurance Policy Holder* Self Spouse Parent/Guardian None of the Above Insurance Company Name Name of Insurance Policy Holder Holder Date of Birth MM slash DD slash YYYY Group Policy/Plan Number ID/Certificate Number Secondary Insurance Company InformationInsurance Policy Holder Self Spouse Parent/Guardian Other Insurance Company Name Name of Insurance Policy Holder Policy Holder Date of Birth Group Policy/Plan Number ID/Certificate Number Financial InformationPerson responsible for account* Self Spouse Parent/Guardian Other Name of Guardian First Last Preferred Method of Payment* Interact Visa Cash Mastercard Dental HistoryDate of your last dental exam MM slash DD slash YYYY Date of your last dental cleaning MM slash DD slash YYYY Date of your last dental xrays MM slash DD slash YYYY Please check any of the following problems that may apply to you.* Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing Headaches, earaches or neck pain Jaw joint pain (clicking/cracking) Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, chipped or shifting teeth Bad breath or bad taste in your mouth None of the above Do you have, or have you had any of the following?* Dentures Orthodontics Partial dentures Periodontal (gum) treatments None of the above If you could change your smile, you would…* Make your teeth brighter Make your teeth straighter Close gaps between teeth Replace metal fillings with natural tooth coloured fillings Repair chipped teeth Replace missing teeth Replace old crowns that don’t match Have a smile makeover None of the above How important is your dental health to you?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhere would you rate your current dental health?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhy are you leaving your previous Dentist? What, if anything, in the past has kept you from having dental treatment? What is the most important thing about your future smile and dental health? What is most important thing to you about your upcoming visit? Medical HistoryThe following information is required to enable us to provide you with the best possible dental care. All information 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.Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Describe:Has there been any change in your general health in the past year?* Yes No Please Describe:Are you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Describe:Do you have any allergies?* Yes No Please Describe:Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Describe:Do you have or have you ever had asthma?* Yes No Do you have or have you ever had any heart or blood pressure problems?* Yes No Please Describe: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 No Please Describe:Do you have a prosthetic or artificial joint?* Yes No Please Describe:Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Describe:Have you ever been hospitalized for any illnesses or operations?* Yes No Please Describe:Do you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) None of the above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Describe:Do you smoke or use other nicotine products?* Yes No Are you breastfeeding or pregnant?* Yes No Do you have a disability or are a person with visual impairment* Yes No Please Describe:General ReleaseI agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.* I agree I do not agree 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 an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this 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. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature aboveDate MM slash DD slash YYYY CHILDREN’S PATIENT FORM Patients Name First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City PhoneBirthDate MM slash DD slash YYYY Parent Name First Last Business Phone: How did you hear about our office? Please check any of the following that apply: Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Is another member of your family, or a relative a patient at our office? Their name: Is this your child's first visit to the dentist? Date of your child's last visit to the dentist: Date of your child's last dental xrays: Date of your child's last dental cleaning: Does your child have any sensitive teeth to hot/cold/sweets to bite on? Does he or she suck on their thumb? Has your child ever had any of the following?Checkbox Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Does your child have or have they ever had any of the following?Please check any of the following that apply: Artificial Heart Valve Heart Murmur Heart Surgery Heart Pacemaker High Blood Pressure Rheumatic Fever Epilepsy or Seizures Fainting or Dizzy Spells Bruise Easily Diabetes: Diet or Medication controlled Hepatitis A Hepatitis B It has been suggested that your child neds pre-medication prior to dental treatment. None of the above For ParentsDo you brush your child teeth? Does your water contain fluoride? Has your child been under medical care during the past two years? Is your child now taking medication? If yes, please list: Has your child had an adverse reaction to any medications? If yes, please explain: Dental InsuranceDo you have dental insurance? Primary Policy Holder Insurance Company Secondary Policy Holder Parent Name ( required for under 18 years ) First Last Parent Signature ( required for under 15 years of age )*Use your mouse or finger to draw your signature above Patient Screening Form Use this form to screen patients before their appointment Staff screener: Patient Name: Date of screening: MM slash DD slash YYYY Have the patient answer the following questions.Q1. Are you immunocompromised? Yes No Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions 2 Fever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smell Muscle aches/joint pain Extreme Sore throat Runny or stuffy/congested Headache Nausea, vomiting and/or diarrhea Abdominal pain Pink eye symptoms Yes No 03: Have you been told (by a doctor, health care provider, public health unit, federal border agent. or other government authority} that you should currently be quarantining,isolating or staying at home? Yes No Q4: In the last lO 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? Yes No Any “yes” response (other than Q1) must be discussed with the managing dentist immediately. Tell the patient that when they arrive at the office, they will be asked to: Sanitize their hands Have their temperature taken (depending on the dental office*s policies). Factors such as old age. diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals: undergoing cancer chemotherapy with untreated HIV infection with CD4 T lymphocyte count less than 200 with combined primary immunodeficiency disorder on prednisone medication - more than 20 mg per day {or equivalent} for more than 14 days on other immune suppressive medications. * Select “No” if all of these apply: you do not have a fever, and your sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea) COVID-19 SCREENING FORM Are you a current or new patient?* New Patient Current Patient Patient Name* First Last Phone*Email* Question 1: Are you immunocompromised and/or live in a highest-risk congregate care setting?* Yes No 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.* Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness Sore taste Runny or stuffy/congested nose Headache Abdominal pain Pink eye none 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?* Yes No 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?* Yes No Date* MM slash DD slash YYYY
