New Patient Medical History

Help us learn a little more about you!

A PDF version of this form can be downloaded below or come to your consult 30 minutes early and we can help you fill out the forms in person.

New Patient Medical History


  • I understand the above information is necessary to provide me with dental care in a safe manner. I have answered all questions truthfully and to the best of my knowledge. I consent to your obtaining, from other practitioners who are currently treating or have treated me such further information as may be necessary for providing me with proper treatment and care.
  • By entering your name here, you consent that the above information is correct to your knowledge.
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  • Medication NameDoseFrequency 
  • If you are unable to fill out this form, please bring your medicine bottles with you to your appointment so that we can assist you in completing this information. Alternatively, with your permission, we can call your pharmacy to request a list of your current medications.

  • SupplementDoseBrandFrequency (i.e., once daily)Duration (length of intake) 
  • Dr. Fritz and Dr. Schuldt are committed to providing their patients with evidence-based care. In doing so, there may be research questions that they would like to answer using data collected during your visit to improve future patient care. Please know that in using such information your personal identity would never be revealed.

  • Please be advised that our office policy is not to accept assignment of benefits as payment for accounts.
  • Primary Insurance
  • Secondary Insurance
  • I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.I also understand that the office of Dr. Peter Fritz and Dr. Luisa Schuldt is a non-assignment office, meaning that all reimbursement cheques will be sent to the insurance subscriber, and that I am personally responsible for payment of my account.
  • By entering your name here, you consent to our Office Policies as they are outlined above.
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  • For Collection, Use and Disclosure of Personal Information

    Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We are as open and transparent as possible about the way that we handle your personal information.

    In this office, Dr. Fritz acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

    In this document, we have outlined what our office is doing to ensure that:
    • Only absolutely necessary information is collected;
    • We only share your information to your other health care providers with your consent;
    • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols;
    • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario (RCDSO) and the law.

    Please, do not hesitate to discuss our policies with any member of our office staff.

    How our Office Collects, Uses and Discloses Personal Patient Information

    This office will collect, use and disclose information for the following purposes:
    • To deliver safe and efficient patient care;
    • To identify and to ensure continuous high quality service;
    • To assess your health needs;
    • To advise you of treatment options;
    • To establish and maintain communication with you;
    • To allow us to efficiently follow-up for treatment, care and finances;
    • To complete and submit dental claims for third party adjudication and payment;
    • To comply with legal and regulatory requirements, including the delivery of patient information and records to the RCDSO in a timely fashion, when required, according to the provisions of the Regulated Health Professionals Act;
    • To comply with agreements/undertakings entered into voluntarily by the member with the RCDSO, including the delivery and/or review of patient information and records to the College in a timely fashion for regulatory and monitoring purposes;
    • To deliver information and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any;
    • To prepare materials for the Health Professions Appeal and Review Board (HPARB);
    • To invoice for goods and services;
    • To process credit card payments;
    • To collect unpaid accounts;
    • To comply with all regulatory requirements and the law.

    By signing below, I have agreed and given my informed consent to the collection, use and/or disclosure of my personal information for the purposes listed above. If a new purpose arises for the use and/or disclosure of my personal information, we will seek your approval and permissions in advance.

    Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the RCDSO fulfilling its mandate under the RHPA, and for the defence of a legal issue.

    Our office will not under any condition supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.

    When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.

    You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.

    I have reviewed the Office Privacy Act that explains how Dr. Peter C. Fritz Periodontal Wellness and Implant Surgery will use my personal information and the steps this office is taking to protect my information.

    I know that the office has a Privacy Code and I can ask to see the Code at any time.

    I agree that Dr. Fritz and Dr. Schuldt can collect, use and disclose personal information about me as set out in the information about the office’s privacy policies.
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