Cochrane Dental Adult Online Patient Forms

Fill out the Adult Forms below and press the submit button after completing each form.
Please fill out the form in its entirety.

Please fill out one Adult form per patient. This will help us speed up the initial check-in process.

PLEASE BE SURE TO REQUEST AN APPOINTMENT BEFORE COMPLETING THESE FORMS


Please select the form you wish to complete below.

 

    Welcome to Cochrane dental! Please kindly complete your Confidential Patient Information form.

    PERSONAL INFORMATION

    INSURANCE INFORMATION

    Primary Insurance Information

    Secondary Insurance Information

      MEDICAL HISTORY

      DO YOU HAVE or HAVE YOU EVER HAD:

      1. hospitalization for illness or injuryYESNO

      2. an allergic or bad reaction to any of the following: YESNO

      3. heart problems, or cardiac stent within the last six monthsYESNO

      4. history of infective endocarditisYESNO

      5. artificial heart valve, repaired heart defect (PFO)YESNO

      6. pacemaker or implantable defibrillator YESNO

      7. orthopedic or soft tissue implant (e.g joint replacement, breast implant) YESNO

      8. heart murmur, rheumatic or scarlet feverYESNO

      9. high blood pressureYESNO

      10. low blood pressureYESNO

      11. stroke (taking blood thinners)YESNO

      12. anemia or other blood disorder YESNO

      13. prolonged bleeding due toa slight cut (or INR greater than 3.5) YESNO

      14. pneumonia, emphysema, shortness of breath, sarcoidosis YESNO

      15. chronic ear infections, tuberculosis, measles, chicken poxYESNO

      16. breathing problems (e.g. asthma, stuffy nose, sinus congestion)YESNO

      17. sleep problems (e.g. sleep apnea, snoring, insomnia,restless sleep, bedwetting) YESNO

      18. kidney diseaseYESNO

      19. liver disease or jaundice YESNO

      20. vertigo (e.g. ”the room is spinning”) YESNO

      21. thyroid, parathyroid disease, or calcium deficiency YESNO

      22. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome) YESNO

      23. high cholesterol or taking statin drugs YESNO

      24. diabetes (HbA1c = YESNO

      25. stomach or duodenal ulcer YESNO

      26. digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia) YESNO

      27. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates) YESNO

      28. arthritis or gout YESNO

      29. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma) YESNO

      30. glaucoma YESNO

      31. head or neck injuries YESNO

      32. epilepsy, convulsions (seizures) YESNO

      33. neurologic disorders (ADD/ADHD, prion disease) YESNO

      34. viral infections and cold sores YESNO

      35. any lumps or swelling in the mouth YESNO

      36. hives, skin rash, hay fever YESNO

      37. STI/STD/HPV YESNO

      38. hepatitis (type YESNO

      39. HIV/AIDS YESNO

      40. tumor, abnormal growth YESNO

      41. radiation therapy YESNO

      42. chemotherapy, immunosuppressive medicationchemotherapy, immunosuppressive medication YESNO

      43. psychiatric treatment or antidepressant medication YESNO

      44. recreational drug use YESNO

      ARE YOU:

      45. presently being treated for any other illness YESNO

      46. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea) YESNO

      47. taking medication for weight management YESNO

      48. taking dietary supplements YESNO

      49. often exhausted or fatigued YESNO

      50. experiencing frequent headaches or chronic pain YESNO

      51. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis) YESNO

      52. have you ever been diagnosed on the Austistic Spectrum or have Sensory issues YESNO

      53. often unhappy or depressed YESNO

      54. taking birth control pills YESNO

      55. currently pregnant YESNO

      56. diagnosed with a prostate disorder YESNO

      57. do you suffer asthma? YESNO

      Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

      Drug & Purpose 1

      Drug & Purpose 2

      Drug & Purpose 3

      Drug & Purpose 4

      PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

        DENTAL HISTORY

        PLEASE ANSWER YES OR NO TO THE FOLLOWING:

        PERSONAL HISTORY
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        GUM AND BONE
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        TOOTH STRUCTURE
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        BITE AND JAW JOINT
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        YESNO
        SMILE CHARACTERISTICS
        YESNO
        YESNO
        YESNO
        YESNO

          Personal Information Consent Form

          We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

          We collect information from our patients such as names, home addresses, home & work telephone numbers, and email addresses. Contact information is collected and used for the following purposes:

          • To open & update patient files.
          • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.
          • To process claims for payment or reimbursement from third‐party health benefit providers and insurance companies.
          • To send reminders to patients concerning the need for further dental examinations or treatment.
          • To send patients informational material about our dental practice.

          Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.

          Financial information may be collected in order to make arrangements for the payment of dental services.

          We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patients’ Medical Information is collected and used for the purpose for diagnosing dental conditions and providing dental treatment.

          Patients’ Medical Information is disclosed:

          • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients’ behalf.
          • To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
          • To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment.
          • To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
          • To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

          If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

          Dentists are regulated by the Alberta Dental Association and College which may inspect or records and interview our staff as part of its regulatory activities in the public interest.

          I Consent to the collection, use and disclosure of my personal information as set out above

            OFFICE POLICIES

            Cochrane Dental Centre is hereby authorized to maintain the “Patient(s)” financial information in its records in order to make arrangements for payment of dental services from the Patient’s benefits provider(s). Cochrane Dental accepts assignment of dental benefits for the Patient’s convenience. Cochrane Dental requires that the Patient provide valid and current credit card information to be maintained on the Patient’s file. Cochrane Dental agrees not to disclose credit card information to third parties or to use credit card information unless authorized by the Patient to do so. The patient hereby agrees that amounts owing after payment of insurance benefits will be charged to the Patient’s credit card unless alternate arrangements are made and agreed to by both Parties.

            With regard to dental health benefit plans, it should be realized that the plan is between the benefits company and the employee (i.e. patient) and as such the details of coverage are unknown to Cochrane Dental. Cochrane Dental will attempt to estimate the cost of the proposed treatment as accurately as possible. However, in the event of a discrepancy between the estimated cost and the actual cost of the treatment, the difference will be the responsibility of the account holder.

            When an estimate is requested, Cochrane Dental will be as accurate as possible. Unfortunately, dental treatment complications cannot be entirely foreseen and hence differences between estimates and actual costs can arise. Once again, the difference will be the responsibility of the account holder.

            CANCELLATION POLICY

            If it becomes necessary to cancel an appointment, I understand that 48 hours notice is required for cancellation of that appointment. There will be a $60 per hour fee for missed or no-show appointments which will immediately be charged to my credit card without further notice.

            Below are 2 payment options available to you (& your account). You will be asked in-office to choose which option you would like to participate in.

            Option 1

            Payment is due in full on the day the treatment is completed. We accept Cash, Debit, MasterCard, Visa & AMEX. Your payment will be processed and your insurance documents will be generated and submitted to your insurance carrier; whereupon your insurance carrier will reimburse you directly.

            Option 2

            We will direct bill your insurance carrier. If we receive an explanation of benefits from your insurance carrier following your visit, the outstanding balance will be collected before you leave. If you select this Direct Billing option, you will be required to leave a CREDIT CARD on file. If there is a balance on your account following your insurance company paying Cochrane Dental Centre, this balance will be charged to the Credit Card on file and a receipt for payment will be emailed to you. A credit card is not required for any Government Sponsored Insurance plans (ie. Alberta Works).

            Direct Billing is a courtesy we offer to our patients and in order 'Direct Bill' your insurance provider, we require a credit card on file or any outstanding amounts owing after your insurance provider has paid their portion. Outstanding account balances over 60 days will be charged 2% interest monthly. I hereby agree to the Financial Policy of Cochrane Dental Centre as outlined above, and authorize Cochrane Dental Centre to apply any outstanding balance on my account that is not covered by my insurance provider to your credit card on file.


            If you have seen a dentist in the last 18 months and would like your X-Rays transferred, please use this form

              X-RAY RELEASE FORM

              To release health care information of the patient name above, to:

              Cochrane Dental Centre

              402 Railway Street W, Unit 10

              Cochrane, AB, T4C 2B6

              Phone: (403) 932-3031

              Email: info@cochrandental.ca

              This request and authorization apply to:

              • Copy of complete dental chart including periodontal measurements
              • Copy of dental x-rays (including Panoramic or FMS)

              I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

              Please note, the Supreme Court of Canada has ruled:

              “A patient is entitled to copies of their dental records provided a signed authorization is received….”

              Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.


              Thank you in advance from the Team at Cochrane Dental!