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

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

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

Preferred Location*

Date*

MM slash DD slash YYYY

NEW PATIENT FORM

How did you hear about us?*

Give some Details:

Select a Location*

Are 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*

Postal Code*

Country*

Email*

Primary Phone Number*

Home Phone Number

Work Phone Number

Best way to contact you:*

Primary

Home

Work

Family Physician*

Specialist Name

Emergency Contact*

Emergency Contact Phone Number*

Insurance Information

Primary Insurance Company

Insurance Policy Holder*

Self

Spouse

Parent/Guardian

None of the Above

Insurance Company Name

Name of Insurance Policy Holder

Holder Date of Birth

MM slash DD slash YYYY

Group Policy/Plan Number

ID/Certificate Number

Secondary Insurance Company Information

Insurance Policy Holder

Self

Spouse

Parent/Guardian

Other

Describe:

Insurance Company Name

Name of Insurance Policy Holder

Policy Holder Date of Birth

Group Policy/Plan Number

ID/Certificate Number

Financial Information

Person responsible for account*

Self

Spouse

Parent/Guardian

Other

Describe:

Preferred Method of Payment*

Interact

Visa

Cash

Mastercard

Dental History

Date 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?*

On a scale of 1 to 10, with 10 being the highest rating

Where would you rate your current dental health?*

On a scale of 1 to 10, with 10 being the highest rating

Why 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 History

The 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

Please Describe:

Has there been any change in your general health in the past year?*

Yes

Please Describe:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Yes

Please Describe:

Do you have any allergies?*

Yes

Please Describe:

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes

Please Describe:

Do you have or have you ever had asthma?*

Yes

Please Describe:

Do you have or have you ever had any heart or blood pressure problems?*

Yes

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

Please Describe:

Do you have a prosthetic or artificial joint?*

Yes

Please Describe:

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Describe:

Have you ever been hospitalized for any illnesses or operations?*

Yes

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

Please Describe:

Do you smoke or use other nicotine products?*

Yes

Please Describe:

Are you pregnant?*

Yes

Expected Due Date

MM slash DD slash YYYY

Are you breastfeeding

Yes

Do you have a disability or are a person with visual impairment*

Yes

Please Describe:

General Release

I 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 above

Date

MM slash DD slash YYYY

CHILDREN’S PATIENT FORM

Patients Name*

First Last

Date*

MM slash DD slash YYYY

Address*

Street Address

City*

Phone*

BirthDate*

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:*

How 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?*

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 Parents

Does 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 Insurance

Do 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*

Patient 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

Address*

City*

Postal code*

Primary Contact Number*

Home Phone

Work Phone

Best number to reach you at?*

Home

Primary Contact Number

Work

Has there been any changes to your emergency contact?

Yes

Emergency Contact First and Last Name*

First Last

Emergency Contact Phone Number*

Name of Family Physician

Person 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

Name of Dental Insurance Company*

Name of Policy Holder*

Certificate Number*

Policy Number*

Date of your last Dental Cleaning

Are you currently being treated for any medical condition or have you been treated within the past year?*

Yes

Please Explain further Details

When was your last medical checkup?*

Has there been any change in your general health in the past year?*

Yes

Please Explain further Details

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Yes

Please Explain further Details

Do you have any allergies?*

Yes

Please list allergies below

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes

Please Explain further Details

Do you have or have you ever had asthma?*

Yes

Please Explain further Details

Do you have or have you ever had any heart or blood pressure problems?*

Yes

Please Explain further Details

Yes

Please Explain further Details

Do you have a prosthetic or artificial joint?*

Yes

Please Explain further Details

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Explain further Details

Have you ever had hepatitis, jaundice or liver disease?*

Yes

Please Explain further Details

Have you ever been hospitalized for any illnesses or operations?*

Yes

Please Explain further Details

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)

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

Please Explain further Details

Do you smoke or use other nicotine products?*

Yes

Are you pregnant?*

Yes

Expected Due Date ?*

MM slash DD slash YYYY

Are you breastfeeding?*

Yes

Do you have a disability or are a person with visual impairment*

Yes

Please Explain further Details

General 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

Reason 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 factors –either dental or medical –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 applies

Referring Clinic Name*

Referring Dentist Name:*

Referring Dentist Phone Number*

Referring Dentist Email*

Please add attachments if needed

Max. 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

Please provide additional details

Required 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