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Patient Registration

Please register by completing our secure online Patient Registration Form. On your first visit we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

PERSONAL INFORMATION

Date: Status: Prefix:

Given Name:  

Family Name:

Address: Apt:
City: Province: Postal Code:

Date of Birth:

Telephone Residence:

Telephone Business: Ext.

Occupation: Referred By:

Person responsible for account:
SelfOther

Dental Insurance: NoYes.

Name of Insurance Company:

Reason for today’s visit:
ExaminationEmergencyOther

Physician Name:

In case of emergency please notify:
Name: Relationship:

Telephone:

MEDICAL HISTORY

The following information is required by the dentist to assist in proper diagnosis and treatment. All information is confidential.

1. Are you presently under the care of a physician? YesNo

2. Have you ever been hospitalized? YesNo
Specify:

3. Do you have a heart or circulatory problem of any kind? YesNo

4. Have you ever had rheumatic fever? YesNo

5. Do you have any allergies? YesNo,
Specify

6. Are you presently taking any kind of medication? YesNo

7. Do you have bleeding problems? YesNo

8. Are you pregnant? YesNo

9. Have you ever had a reaction to any knd of medicine? YesNo ,
Specify:

10. Do you presently or have you ever had (Hold CTRL to make multiple selections):

11. Have you ever had concussion? YesNo

12. Have you ever fainted? YesNo

13. have you ever had any illness not included above? YesNo

14. have you ever had local anaesthetic? YesNo

PATIENT CERTIFICATION AND APPROVAL
I, the undersigned certify the all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

Patient (Parent, Guardian) Signature , Date:

PATIENT (GUARDIAN) CONSENT (FOR MINORS)
I, the undersigned, consent to the performing of dental and oral surgery procedures agree to be necessary or advisable, including the use of local unaesthetic as indicated, and I will assume responsibility for fees associated with these procedures.

Parent (Guardian) Signature , Date:


Your Email (required)


COVID-19 PANDEMIC OFFICE PROTOCOL:

During the COIVD-19 Pandemic and as per ADA and Mass Department of Health and Safety, our office is closed until further notice to elective dental/endodontic care. During this time, we may be able to accommodate some urgent dental emergencies after a telephone interview. Our office manager and front desk is taking telephone calls and trying to triage patients with acute pain. For safety of our dental staff, patients are triaged for symptoms of COVID-19 prior to their arrival at our office. Please call the office at 416-781-5251 for more information about this protocol. Note: Office appointments may take longer to allow for a more rigorous protocol of disinfection of all surfaces between patients following the CDC and OSHA standards for our collective safety. At York Hill Endodontics, we are committed to the highest standards of safety during your care under our supervision. When you arrive to the office, you will be asked to wash your face and hands before filling out forms. If you feel sick or are under the weather, we ask you to stay home until your symptoms are fully resolved. We are unable to treat patients with signs and symptoms of a cold, coughing, fever, sneezing, and other manifestations of an upper respiratory tract infection until those symptoms are fully resolved. We appreciate your understanding during this pandemic and our vigilance to provide the safest possible care to our patients and staff.