NEW PATIENT REGISTRATION

Parent/Responsible Party

PLEASE EXPLAIN
PLEASE EXPLAIN

Dental Insurance Information

Are you covered by any of the following government assisted DENTAL programs?


Dental History

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PLEASE EXPLAIN
PLEASE EXPLAIN
PLEASE EXPLAIN

HEALTH QUESTIONNAIRE

Does the patient have or ever had any of the following diseases or conditions?

Has the patient ever experienced any unusual reactions or allergies to any of the following drugs?

Please Explain
Please Explain

I understand that the information that I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services with my informed consent that I may need during diagnosis and treatment.

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Consent Release Information

Privacy Notice Acknowledgement (PIPEDA)

My signature authorizes Regina Orthodontic Group to release any medical records or other information for purposes such as treatment or health care operations. I understand that this information can and will be used to:

  • Conduct, plan and direct treatment and follow up amongst the multiple healthcare providers who may be involved in the treatment directly and indirectly.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
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