Patient form

106 – 11012 MacLeod Trail SE Calgary,
AB T2J 6A5
(Ground Floor of Southcentre Executive Tower)

403.768.2791

Thank you for visiting us at Willow Park Dental. We would like to make your visit as pleasant and comfortable as possible.
Please help us by completing this form to the best of your ability. Feel free to ask us if there are any questions.

How did you hear about us?

What is the reason for today’s visit?

Patient Information

Name:

Street Address

City

Postal Code

Email

Employer

Province

Home No.

Cell No.

Date of Birth

Emergency Contact Information

Name:

Phone No.

General Consent for Treatment and Privacy Policy (In Accordance with the Alberta Personal Information Protection Act)

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and email
addresses. Collectively referred to as “Contact Information”. Contact Information is collected and used for the following purposes:

  • To open and 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 examination 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”. Patient’s Medical Information is collected
and used for the purpose of diagnosing dental conditions and providing dental treatment.

Patient’s 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 patient’s 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 our records and
interview our staff as part of its regulatory activities in the public interest.

I authorize and give consent to perform dental services agreed upon between myself and the doctor/auxiliary staff of Willow Park Dental. I certify that, to the best of my knowledge, the information provided in my Health History is accurate and correct.
If I ever have any changes in my health, I will inform this clinic at the next appointment without fail. I consent to the collection,
use and disclosure of my personal information as set out in the office Privacy Policy.

Patient Signature

Date:

Staff Signature: