Covid-19 Screening Form Please fill out the mandated COVID-19 Screening Form below before your next appointment. Are you a current or new patient?* New Patient Current Patient Patient Name* First Last Phone*Email* Question 1: Are you immunocompromised and/or live in a highest-risk congregate care setting?* Yes No Question 2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.* Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness sore throat Runny or stuffy/congested nose Headache Abdominal pain Pink eye none Question 3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other goverment authority) that you should currently be quarantining, isolating or staying at home?* Yes No Question 4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?* Yes No Preferred Location*Select locationAlta VistaBayshoreKanataJackson TrailsWestgateDowntownOrléansDate* MM slash DD slash YYYY NEW PATIENT FORM How did you hear about us?*SelectPatient ReferralLives in AreaWorks in BuildingRadioSocial MediaCDCPGive some Details:Select a Location*Select locationAlta VistaBayshore MallDowntown OttawaKanataOrléansJackson TrailsWestgate MallAre you a new or current patient?* New Patient Current Patient Patient Contact Information Patient Type* Adult Child Adult Under Guardianship Name of Guardian* First Last Gender* Male Female Other Other:Name of Patient* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address City*Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Country*Select countryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombia" "ComorosCongoCongo, The Democratic Republic of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-bissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenEswatiniSwedenSwitzerlandSyrian Arab RepublicTaiwan (ROC)TajikistanTanzania, United Republic ofThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweEmail* Primary Phone Number*Home Phone NumberWork Phone NumberBest way to contact you: Primary Home Work Preferred Time to Contact Hours : Minutes AM PM AM/PM Preferred Method of Contact*Family Physician*Specialist NameEmergency Contact*Emergency Contact Phone Number*Insurance InformationPrimary Insurance CompanyInsurance Policy Holder* Self Spouse Parent/Guardian None of the Above Insurance Company NameName of Insurance Policy HolderHolder Date of Birth MM slash DD slash YYYY Group Policy/Plan NumberID/Certificate NumberSecondary Insurance Company InformationInsurance Policy Holder Self Spouse Parent/Guardian Other Describe:Insurance Company NameName of Insurance Policy HolderPolicy Holder Date of BirthGroup Policy/Plan NumberID/Certificate NumberFinancial InformationPerson responsible for account* Self Spouse Parent/Guardian Other Describe:Preferred Method of Payment* Interact Visa Cash Mastercard Dental HistoryDate of your last dental exam*Date of your last dental cleaning*Date of your last dental x-rays*Please check any of the following problems that may apply to you.* Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing Headaches, earaches or neck pain Jaw joint pain (clicking/cracking) Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, chipped or shifting teeth Bad breath or bad taste in your mouth None of the above Do you have, or have you had any of the following?* Dentures Orthodontics Partial dentures Periodontal (gum) treatments None of the above If you could change your smile, you would…* Make your teeth brighter Make your teeth straighter Close gaps between teeth Replace metal fillings with natural tooth coloured fillings Repair chipped teeth Replace missing teeth Replace old crowns that don’t match Have a smile makeover None of the above How important is your dental health to you?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhere would you rate your current dental health?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhy are you leaving your previous Dentist?What, if anything, in the past has kept you from having dental treatment?What is the most important thing about your future smile and dental health?What is most important thing to you about your upcoming visit?Medical HistoryThe following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Describe:Has there been any change in your general health in the past year?* Yes No Please Describe:Are you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Describe:Do you have any allergies?* Yes No Please Describe:Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Describe:Do you have or have you ever had asthma?* Yes No Please Describe:Do you have or have you ever had any heart or blood pressure problems?* Yes No Please Describe:Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Please Describe:Do you have a prosthetic or artificial joint?* Yes No Please Describe:Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Describe:Have you ever been hospitalized for any illnesses or operations?* Yes No Please Describe:Do you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) None of the above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Describe:Do you smoke or use other nicotine products?* Yes No Please Describe:Are you pregnant?* Yes No Expected Due Date MM slash DD slash YYYY Are you breastfeeding Yes No Do you have a disability or are a person with visual impairment* Yes No Please Describe:General ReleaseI agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.* I agree I do not agree I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature aboveDate MM slash DD slash YYYY CHILDREN’S PATIENT FORM Patients Name* First Last Date* MM slash DD slash YYYY Address* Street Address City*Phone*Date of Birth* MM slash DD slash YYYY Parent Name* First Last Primary Phone Number:*Work Phone Number:Home Phone Number:Best way to contact you:* Home Primary Work For preferred Trillium Dental Location, please select from dropdown list below:*Select locationDowntownAlta VistaBayshoreKanataJackson TrailsOrléansWestgateHow did you hear about our office?*Please check any of the following that apply:* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Is another member of your family, or a relative a patient at our office?* Yes No Their name:*Is this your child's first visit to the dentist?*Date of your child's last visit to the dentist:*Date of your child's last dental xrays:*Date of your child's last dental cleaning:*Does your child have any sensitive teeth to hot/cold/sweets to bite on?*Does he or she suck on their thumb?*Has your child ever had any of the following?* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Does your child have or have they ever had any of the following?* Artificial Heart Valve Heart Murmur Heart Surgery Heart Pacemaker High Blood Pressure Rheumatic Fever Epilepsy or Seizures Fainting or Dizzy Spells Bruise Easily Diabetes: Diet or Medication controlled Hepatitis A Hepatitis B It has been suggested that your child needs pre-medication prior to dental treatment. None of the above Please check any of the following that apply:For ParentsDoes your child need aid when brushing their teeth?*Does your water contain fluoride?*Is your child currently taking any prescribed medications?*Has your child ever reacted to any type of medications?*Has your child had any serious injury/illness within the past two years that required medical attention?*Dental InsuranceDo you have dental insurance?*Primary Policy Holder*Insurance Company*Secondary Policy Holder*Parent Name ( required for under 18 years )* First Last Parent Signature ( required for under 15 years of age )*Use your mouse or finger to draw your signature above Update medical history Select a Location*Select locationAlta VistaBayshore MallDowntownKanataOrléansJackson TrailsWestgate MallPatient Type* Adult Child Adult Under Guardianship Guardian Name:* First Last Email* Self Identification* Man Woman Other Other:Name of Patient* First Last Date of Birth* MM slash DD slash YYYY Has there been any changes to your address recently?* Yes No Address*City*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code*Primary Contact Number*Home PhoneWork PhoneBest number to reach you at?* Home Primary Contact Number Work Has there been any changes to your emergency contact? Yes No Emergency Contact First and Last Name* First Last Emergency Contact Phone Number*Name of Family PhysicianPerson Financially Responsible for the account* Self Spouse Parent/Guardian Other Other:Preferred Method of Payment* Cash Interact Visa Mastercard Has there been any changes to your insurance information? Yes No Name of Dental Insurance Company*Name of Policy Holder*Certificate Number*Policy Number*Date of your last Dental CleaningAre you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Explain further DetailsWhen was your last medical checkup?*Has there been any change in your general health in the past year?* Yes No Please Explain further DetailsAre you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Explain further DetailsDo you have any allergies?* Yes No Please list allergies belowHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Explain further DetailsDo you have or have you ever had asthma?* Yes No Please Explain further DetailsDo you have or have you ever had any heart or blood pressure problems?* Yes No Please Explain further DetailsDo you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Please Explain further DetailsDo you have a prosthetic or artificial joint?* Yes No Please Explain further DetailsDo you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Explain further DetailsHave you ever had hepatitis, jaundice or liver disease?* Yes No Please Explain further DetailsHave you ever been hospitalized for any illnesses or operations?* Yes No Please Explain further DetailsDo you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) loss of hearing difficulty hearing None of the above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Explain further DetailsDo you smoke or use other nicotine products?* Yes No Are you pregnant?* Yes No Expected Due Date ?* MM slash DD slash YYYY Are you breastfeeding?* Yes No Do you have a disability or are a person with visual impairment* Yes No Please Explain further DetailsGeneral Release I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature above DENTIST REFERRAL Periodontist Referral Dr. Sherif Said Dr. Freddy Fokam Oral Surgeon Referral Dr. Amin Alibhai IV Sedation Referral Dr. Kirsty Large Reason for periodontist referral: Periodontal Disease/Gum Pockets Gum Recession/Gingival Graft Crown-Lengthening Biopsy Implants Oral Surgery Other Other*Reason for IV sedation referral: Extractions Crown & Bridge General Restorative Periodontal Care Endodontic Therapy Implants Other OtherReason for oral surgeon referral Implant Biopsy Extraction Other Other:We are introducing:* First Last Date of Birth* MM slash DD slash YYYY Email* Phone*Appointment* Patient has an appointment Patient to call for an appointment Please call patient for an appointment Comments*Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.Relevant History*Indicate any special dental or medical factors, such as allergies and medical problems relevant to diagnosis and treatment.Digital Radiographs* Attached Patient to Bring No Radiographs Radiographs* Panoramic Bitewing Periapical Select all that appliesReferring Clinic Name*Referring Dentist Name:*Referring Dentist Phone Number*Referring Dentist Email* Please add attachments if neededMax. file size: 6 GB.Date of Referral* MM slash DD slash YYYY SLEEP APNEA FORM Please check the box that best relates to your symptoms.*Required to fill for next section completion* I have been told that I snore My snoring is loud and bothers others I have been told that I stop breathing when I sleep I suddenly wake gasping for breath I frequently wake with a dry mouth I have problems breathing through my nose I have noticed my heart pounding or beating irregularly during the night I often wake up with headaches My friends and family say that I’m grumpy and irritable I have fallen asleep while driving I often fall asleep as a passenger in a vehicle for an hour or more I tend to nod off watching TV, reading or sitting quietly I am often tired through the day I often feel sleepy during the day and struggle to remain alert I have trouble concentrating at work I am overweight I have high blood pressure None of the above (Q 1 – 17: If you marked 3 or more boxes, you show symptoms of Sleep Apnea) Please check the next section that applies. If not please check no.* No I have not marked 3 or more boxes. I have seen a doctor about snoring or sleep apnea. I have had a lab sleep study. Required to fill for next section completion"I suffer from memory loss." Yes No Please provide additional detailsRequired to fill for next section completion* I suffer from depression I have a problem with my jaw My jaw locks My jaw hurts My jaw clicks I often clench and/or grind my jaw None of the Above Please submit your first and last name below. Both are required.* First Last Date* MM slash DD slash YYYY