Fill Out Your Forms Online — Auburn Centre Dental, Waterloo

Patient Information

About you

Title

Name

Prefers to be called

Date of birth

Home address

Home phone

Cell phone

Email

Occupation

Business address

Business phone

Extension

May we call you at work?

Yes No

How did you hear about our office?

In case of emergency, we should notify

Name

Relationship

Daytime phone

Physicians

Family physician

Family physician — phone and address

Medical specialist (1)

Area of specialty

Phone and address

Medical specialist (2)

Area of specialty

Phone and address

Primary insurance

Insurance company

Subscriber’s name

Subscriber’s date of birth

Employer

Group policy number

Division number

ID / certificate number

Secondary insurance

Insurance company

Subscriber’s name

Subscriber’s date of birth

Employer

Group policy number

Division number

ID / certificate number

Insurance authorization

I authorize release, to my dental benefits plan administrator and the CDA, of information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization continues until I revoke it.

Please note: our relationship is with you, not your insurance company. The relationship you have with your insurance company is your responsibility.

Prefer paper? Download the Patient Information PDF.

Medical History

Recent medical care

Are you seeing a physician at the present time for the treatment of a recent or ongoing medical condition?

Yes No

If yes, explain

Have you been hospitalized within the last year?

Yes No

If yes, explain

Have you had a serious illness or operation within the last year?

Yes No

If yes, explain

Have you ever had any serious medical trouble associated with any dental experience?

Yes No

If yes, explain

Have you ever been advised to take antibiotics (like penicillin) before a dental appointment?

Yes No

If yes, explain

Heart and circulation

Cardiovascular disease?

Yes No

If yes, check any that apply

Heart attack or stroke — when?

Rheumatic fever or rheumatic heart disease

Yes No

Infective endocarditis

Yes No

Congenital heart defects

Yes No

Prosthetic (artificial) heart valves

Yes No

Pacemaker

Yes No

If yes, date of placement

High cholesterol

Yes No

Shortness of breath

Yes No

Do your ankles swell?

Yes No

Do you have chest pain upon exertion?

Yes No

Abnormal bleeding or extended clotting time

Yes No

Frequent or unexpected nose bleeds

Yes No

Have you ever required a blood transfusion?

Yes No

If yes, what was the date of the transfusion?

Other conditions

Are you HIV positive?

Yes No

Do you have any reason to suspect that you have been exposed to the HIV virus?

Yes No

Hepatitis?

Yes No

Diabetes?

Yes No

If yes, do you require insulin?

Yes No

Type and dose

Do you have an artificial joint?

Yes No

If yes, which joint(s)?

Have you ever had tuberculosis (TB)?

Yes No

Have you ever had a TB test?

Yes No

Do you have a cough that has lasted more than 3 weeks?

Yes No

Do you ever cough up blood?

Yes No

Have you tested positive for Covid-19?

Yes No

Cancer?

Yes No

If yes, type of cancer and date diagnosed

Oncologist name

Cancer treatments (chemotherapy or radiation, and cycle)

Last blood count

Central line?

Yes No

Check any that apply

Other

When was your last complete physical exam with your medical doctor, including blood tests?

Medications

List all names of drugs and doses

Allergies

Are you allergic to any of the following (hives, a rash, trouble breathing, etc.)? Check any that apply.

Antibiotics (penicillin, tetracycline, etc.)

Local or topical dental anesthetics (novacaine)

Codeine

Aspirin

Barbiturates or sedatives

Tranquilizers

Food (dairy)

Cortisone (steroids)

Latex

Other allergies

Lifestyle and general health

Do you now, or have you ever, smoked?

Yes No

If you currently smoke, how many or how much per day?

If you have smoked in the past but no longer smoke, when did you quit?

Do you use marijuana / cannabis?

Yes No

How often?

Do you chew tobacco?

Yes No

If yes, how often?

Do you drink alcohol?

Yes No

If yes, how much?

Are you currently on hormone replacement therapy?

Yes No

Have you ever had an adverse reaction like nausea, dizziness, or feeling “spacey” with any drug or medication?

Yes No

Do you have any disease, condition or problem not previously listed that you feel we should know about?

Yes No

If yes, tell us about it

(Women) Are you currently pregnant?

Yes No

Expected delivery date

Dental history

Date of last dental / dental hygiene visit

What dental conditions concern you at the present time?

What care did you receive at the last dental visit?

How often do you receive dental treatment or dental hygiene care?

Do you require complete mouth care or emergency treatment?

Are you under the care of a dental specialist (orthodontist, endodontist, prosthodontist, periodontist)?

Yes No

If yes, type

Have you ever had a thorough exam of your mouth including a complete set of radiographs (16–20 films) of your jaws and teeth?

Yes No

If yes, when?

Have you had X-rays in the past two years?

Yes No

Have you had any dental problems within the last year with your teeth, gums, jaw, or chewing?

Yes No

So we can be sensitive to your dental needs, please tell us of any unpleasant experiences you may have had related to oral care.

Prefer paper? Download the Medical History PDF.

Financial Policy

The policy

In order for us to meet the needs of our patients and to avoid some patients compensating the delinquency of others, we have set out the following financial policy.

Our office expects payment for services on the day they are rendered. We accept Cash, Debit/Interact, Visa, MasterCard, and American Express. Interest may be charged on overdue accounts at the rate of 1.5% per month.

Auburn Centre Dental offers financing through an independent company named Medicard. This payment option has the advantage of keeping the relationship between doctor and patient unencumbered by collection processes. During a dental emergency, we want you to feel free to contact our office immediately and not have to consider if your account is currently in arrears. It is suitable for both the patient and Dr. Bansal to have payment retrieved within a third party such as Medicard. Their acceptance rate is high, quickly obtained and is open ended (you can pay them off when you want). This is ideal for expensive treatment plans where insurance will pay you a large portion but you would otherwise have a large upfront cost while waiting.

It is not our office policy to accept personal cheques, current or post-dates as the office offers the Debit system. If exception to our policy occurs and a personal cheque is returned due to insufficient funds, we reserve the right to add a $30 service charge to your existing account to cover any banking fees.

We are happy to provide electronic submission of any insurance claims which expedites your reimbursement from your insurance company. Since there are numerous companies and policies, we cannot predict what services will/will not be covered by your plan, or by how much. Your administrative/personnel department at your workplace should be able to supply you with such information pertaining to frequency of recall visits, percentages, annual maximums, anniversary dates, etc. We will, at no additional fee, do what we can to assist you in obtaining information regarding covered services with your insurance carrier.

We appreciate 48 hours notice if an appointment must be rescheduled. When a time has been set aside for you, no other patient has access to this time. We reserve the right to add a cancellation fee for missed appointments or appointments with insufficient notice (if original appointment length was an hour or less = $30 / an hour or greater = $60). We do realize unforeseen circumstances can occur and appreciate when notice is provided, however little.

When services involve multiple appointments and laboratory charges, we expect payment at the first appointment of the expected lab charge. During the subsequent appointment the true lab fee and Doctor’s fee are added, less the estimated lab charge collected prior.

Larger treatments such as orthodontics, multiple unit implants, crowns, bridges, etc. will involve slightly altered payment agreements which will be explained to you prior to any appointment or anticipated treatment.

I have read and understand the Auburn Centre Dental financial policy.

Prefer paper? Download the Financial Policy PDF.

How our office collects, uses and discloses patients’ personal information

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

To assess your health needs and provide safe and efficient dental care.
To enable us to contact and maintain communication with you to distribute health-care information and to book and confirm appointments.
To communicate with other treating health-care providers, including other dentists, physicians, pharmacists and lab technicians.
For teaching and demonstrating purposes on an anonymous basis.
To complete and submit dental claims for third party adjudication and payment.
To comply with legal and regulatory requirements.
To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, as necessary.
To invoice for goods and services.
To process credit card payments.
To collect unpaid accounts.

Thank-you for your support and understanding, helping our office to comply with all regulatory requirements, and generally with the law.

I understand how this office collects, uses and discloses my personal information, as described above.

Prefer paper? Download the Privacy Consent PDF.

Sign and send

Full name (acts as your signature)

I confirm the information above is complete and accurate as far as I know.

I understand these forms are sent to Auburn Centre Dental by email, and the practice may reply to me by email.

Your answers are emailed directly to Auburn Centre Dental and stored nowhere else. Prefer paper? Download the forms and bring them to your visit.

Fill out your forms.

Patient Information

About you

In case of emergency, we should notify

Physicians

Primary insurance

Secondary insurance

Insurance authorization

Medical History

Recent medical care

Heart and circulation

Other conditions

Check any that apply

Medications

Allergies

Lifestyle and general health

Dental history

Financial Policy

The policy

Sign and send

Forms received.

Fill out your forms.

1 Patient Information

About you

In case of emergency, we should notify

Physicians

Primary insurance

Secondary insurance

Insurance authorization

2 Medical History

Recent medical care

Heart and circulation

Other conditions

Check any that apply

Medications

Allergies

Lifestyle and general health

Dental history

3 Financial Policy

The policy

4 Privacy Consent

How our office collects, uses and discloses patients’ personal information

5 Sign and send

Forms received.

Patient Information

Medical History

Financial Policy

Privacy Consent

Sign and send