New Patient Form 2018-10-02T19:10:40+00:00
We are dedicated to preventative dentistry and our aim is to help keep your child’s teeth healthy for a lifetime. To help us treat your child, the following information is requested. Please fill out this form and complete it before your first visit

Patient Information

SEX: MaleFemale

Parent or Guardian Information

Dental Insurance Information

As your dental plan is a contract between you and your carrier, we encourage you to be completely familiar with the terms of your plan. We are a fee for service office and full payment is to be made at the time services are rendered.For your convenience, we accept Mastercard, Visa, debit, and cash. We do not accept cheques. Our staff will assist in processing your insurance claim forms and where applicable, file them electronically for you to ensure maximization of insurance benefits and rapid reimbursement.

PRIVATE INSURANCE: YesNo
NIHB/FIRST NATIONS: YesNo
OTHER: YesNo

Dental History

Is your child currently experiencing any dental pain? YesNo

Is this your child’s first visit to a dentist? YesNo

Has your child had an unfavorable dental/medical experience in the past? YesNo

Has your child ever injured his/her teeth or mouth? YesNo

Has your child ever taken Fluoride tablets or drops? YesNo

Do you brush your child’s teeth? YesNo

Do you floss your child’s teeth? YesNo

Does your child go to bed with a bottle? YesNo

Does your child use a sippy cup? YesNo

Does your child suck fingers or thumb or have a similar habit? YesNo

Does your child participate in sports activities? YesNo

Medical History

Has your child had any of the following?
(please check if yes)

Heart diseaseHeart murmurRheumatic feverCongenital heart defectBlood DisordersBlood transfusionMalignant hyperthermiaLiver diseaseHepatitisKidney diseaseHIV/AIDSInfectious diseaseBone or muscle problemsProsthetic jointAsthmaSleep apneaRecurrent headachesFainting spellsSeizuresCerebral palsyCancer/tumorsDiabetesVisual, hearing or sinus problemsAnemiaSkin problems (eg. eczema)Stomach ulcersSpeech problemsCleft lip/palateEndocrine/growth problemsEmotional/Social problemsAutismBehavioral problemsOther

1. Has your child ever been hospitalized or had an operation?
YesNo

2. Is your child being treated for any medical condition at the present
time or within the past year? YesNo

3. Has you child ever had general anesthesia before? YesNo

4. Are your child’s immunizations up-to-date? YesNo

5. Were there any complications surrounding the pregnancy or birth
of your child? YesNo

6. Has your child ever had prolonged bleeding following a tooth
extraction or minor injury? YesNo

7. Is your child taking any medication, non-prescription drugs or
herbal supplements of any kind? YesNo

8. Is your child allergic to any medication (penicillin, pain killers, sulfa
drugs, etc.)? YesNo

I, the undersigned, verify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my physician being contacted if necessary to obtain information that is required for my child’s dental care. I authorize the dentist to perform the diagnostic procedures that may be required to determine the necessary treatment and assume financial responsibility for dental services rendered for my child.

Patient Privacy Consent

Privacy of your personal information is an important part of our office. We understand the importance of protecting your personal information. 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 important to us to provide this service to our patients.

In this office, Dr. Jennifer Howson-Jones 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. Do not hesitate to discuss our policies with any member of our office staff.

At Primary Care Pediatric Dentistry, we ensure that only necessary information is collected about you; we only share your 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 privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of British Columbia,and the law.

We will collect, use and disclose information about you for the following purposes:

  • to deliver safe and efficient patient care
  • to ensure continuous high quality service
  • to assess your health needs
  • to advise you of treatment options
  • to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
  • to enable us to contact and maintain communication with you, to book and confirm appointments
  • to allow us to efficiently follow-up on your treatment and on-going care
  • to facilitate the billing process
  • to complete and submit dental claims on your behalf
  • to comply with legal and regulatory requirements according to the provisions of the Regulated Health Professions Act and also for other regulatory and monitoring purposes
  • to present individual cases for teaching and demonstrating purposes on an anonymous basis

Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.

By signing the consent section of this Patient Privacy Consent Form (below), 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. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

PATIENT PRIVACY CONSENT
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Dr. Jennifer Howson-Jones Inc. can collect, use and disclose personal information about


as set out above in the information about the office’s privacy policies.

New Courses

Contact Info

1600 Amphitheatre Parkway New York WC1 1BA

Phone: 1.800.458.556 / 1.800.532.2112

Fax: 458 761-9562

Web: ThemeFusion

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