NEW PATIENT FORM
PATIENT INFORMATION
d Minor d Single d Married/ Common-law
Last Name:Ali First:Syed Hamzah
Birth date:July 23 2002 Age: 21 Occupation:student Employer:
Address:14 dass drive east City:fergu Province:ontario Postal Code:n1m0h2
s
Phone Number: Email: Emergency Contact Name:Nazia Rehman
647-985-1162
[email protected] Emergency Contact Number:
647-960-1162
How did you hear about us?
• Google Search Newspaper/Magazine Signage Event
• Social Media Referred by a Friend - Name of Friend: _________________________
Other: ______________________________________
Other Family Members here: _________________________________________________________
INSURANCE INFORMATION
INSURANCE#1 Policy Holder’s Birth Member ID:635724359 Carrier:Manulife Group/Policy Numbe
Subscribers Name: Date: r: 0121783
Nazia Rehman
INSURANCE#2 Policy Holder’s Birth Member ID: Carrier: Group/Policy Number:
(if applicable) Date:
Subscribers Name:
BILLING – Dr. McKeown and Associates offers the
following payment options. Please choose which option you Employment Status
would like to participate in.
Option 1 – This requires you to pay in full the day of Employment Status: Full Time Part Time Retired
treatment. We accept VISA, MasterCard, Cash, and Debit. Our
dental administrative staff will assist you with preparing and Student Status: Full Time Part Time
submitting claims to your insurance if necessary.
Medical Information
Option 2 – We accept Direct Billing or assignment of
benefits. The assignment of benefits means your insurer pays
Medical Doctor: ____Dr.Brock___________________
your dentist directly. The dental claim can be submitted to the
insurance company by our dental office. All you need to do is
Pharmacy: _____________________
provide our staff with your benefit plan number and/or benefits
card. Any fees that are not covered by your plan must be paid
by you to the dentist on the day of service.
DENTAL HISTORY
Do you have a specific dental problem?
Do you have dental examinations on a regular basis?
Do you feel nervous having dental treatment done?
Have you had Orthodontic treatment done?
Do you have chronic “tension headaches”/
neck or shoulder pain?
Do you clench or grind your teeth during
the day, or at night?
Do you ever have clicking or cracking sound in your jaw
joints or difficulty opening your mouth wide?
Do you wear a night guard?
Do your gums bleed when you brush your teeth?
Are any teeth sensitive to temperature or pressure?
Approximate date of last check-up?
History of Snoring?
X-rays taken?
How often do you brush?
Floss? How often?
MEDICAL HISTORY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your
entire body. Health problems that you may have, or medication that you may be taking, could have an
important interrelationship with the dentistry you will receive. Thank you for answering the following
questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Please provide a list of your medications below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are you taking any blood thinners?
Have you ever taken Fosamax, Boniva, Actonel
or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use marijuana products?
Women: Are you…
d Pregnant/Trying to get pregnant?
d Nursing?
d Taking oral contraceptives?
Are you allergic to any of the following?
d Aspirin d Penicillin d Codeine d Acrylic d Local Anesthetics d Sulfa Drugs d Latex
d Amoxicillin
Other? d YES d NO If Yes:
_________no____________________
Do you use controlled substances? d YES d NO If Yes:
__________no___________________
Do you have, or have you had, any of the following?
• AIDS/HIV Positive
• Alzheimer’s Disease
• Anaphylaxis
• Anemia
• Angina
• Arthritis/Gout
• Artificial heart Valve
• Artificial Joint
• Asthma
• A Tumor or Abnormal
growth?
• Aware of any change in
your general health in the
past year?
• Aware of any recent
weight change?
• Blood Disease
• Blood Transfusion
• Breathing Problems
• Bruise Easily
• Cancer
• Chemotherapy
• Chest Pain
• Cold Sores/Fever Blisters
Have you ever had any serious illness not listed?
d YES d NO If Yes:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that
providing incorrect information can be dangerous to my (or my patient’s) health. It is my responsibility to
inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian:
Syed Hamzah Ali Date:
INFORMATION RELEASE
I hereby authorize _____Crystal Dental (875 St David St N Unit 302, Fergus, ON N1M
2W3)________________________________________________________,
(Former Dental Office) to release any relevant records and radiographs to Dr. Maura McKeown and
Associates on my behalf.
________Syed Hamzah Ali_________________________
(name of patient)
Please provide the following information:
Date of last recall: __more than 1 year __________________
Date of last new patient exam: ____more than 1 year ________________
Date of last bite wings/PA’s: ____________________
Date of last PAN film: _________More than 1 year ___________
I release you from all legal responsibility or liability that may arise from this authorization.
Signature of Patient: _______________________Syed Hamzah Ali_____________________
Date: _________Feb 13/2024 ________________________________________
Email: [email protected]
FAX: 519-787-4332
Patient Consent Form: Collection, Use and Disclosure of Personal
Health Information
Privacy of your personal health information is an important part of our office providing you with quality dental care. We
understand the importance of protecting your personal health information. We are committed to collecting, using and
disclosing your personal health information responsibly. We also try to be as open and transparent as possible about
the way we handle your personal health information. It is important to us to provide this service to our patients.
In this office, Dr. Maura McKeown is the contact person for personal health information related matters.
All staff members who come in contact with your personal health 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.
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 your information is collected about you
● Storage, retention and destruction of your personal health information complies with existing legislation, and
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 me or any member of our office staff.
Patient Privacy Consent
I have received and reviewed a copy of the Privacy Statement regarding Collections, Use and Disclosure of Patients’
Personal Information, which explains how your office will use my personal information, ad the steps your office is
taking to protect my information.
I know that your office has a Privacy Code and I may ask to see the Code any time.
I agree that Dr. McKeown and Associates can collect, use and disclose personal information about myself as set out
above in the information about the office’s privacy policies.
Short notice Cancelation and No/Show policy
We require 2 business days notice to cancel/change appts. A $50 fee may be applied
for week day No Show visits or short notice cancellations. A $100 fee may be applied
for No Show visits for Saturday appointments.
_____Syed Hamzah aLI ____________________________
________________________________
Signature Print Name Syed hamzah ali
______Feb 13/2024 ___________________________
Date
