Patient Medical History

For Referring Offices: Refer a Patient

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.

Patient Medical History

"*" indicates required fields

Step 1 of 9

Basic Contact Info

First Name*

Last Name*

Date of Birth*

Address*

Street Address City Province Postal Code

Main Phone Number*

Alternate Phone Number

Which number would you like to receive SMS messages to?*

Main Phone Number

Alternate Phone Number

Neither

Your Email Address*

How would you like to receive appointment related correspondence?*

Text Message (SMS)

Phone

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship*

Employer

Occupation

Dental Insurance Information

Please be advised that our office policy is not to accept assignment of benefits as payment for accounts.

Primary Insurance

First and Last Name of Policy Holder

Policy Holder's Date of Birth

Insurance Company

Plan/Policy/Group Number

Subscriber/Certificate Number

Place of Employment

Relationship of Patient to Policy Holder*

Self

Dependant

Spouse

Secondary Insurance

First and Last Name of Policy Holder

Policy Holder's Date of Birth

Insurance Company

Policy/Group Number

Subscriber/Certificate Number

Place of Employment

Relationship of patient to policy holder

Dependant

Spouse

Self

Is this an accident claim?*

Yes

Accident Claim Number

Consent

Consenting Signature*

By entering your name here, you consent to our Office Policies as they are outlined above.

Date*

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.

Name*

First Last

Date*

How did you hear about us? (Dentist, Hygienist, Friend, etc.)*

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