Covid-19 Screening Form

Please fill out the mandated COVID-19 Screening Form below before your next appointment.

    Medical History

    * A fully immunized individual is defined as any individual >14 days after receiving their second dose of a
    two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson
    and Johnson).

    NEW PATIENT FORM

      Patient Contact Information

      MaleFemaleOther

      Insurance Information

      Primary Insurance Company

      Secondary Insurance Company Information

      Financial Information

      Dental History


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

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

      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.

      General Release

      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.*
      Use your mouse or finger to draw your signature above

      PATIENT CONSENT FORM

        Privacy of Personal Information

        (for collection, use and disclosure of personal information)

        Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is very important to us to provide this service to all of our patients.

        In this dental office, the Office Manager 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. Here is an outlined policy that our office follows to ensure you that:

        • Only the necessary information is collected from you.
        • We only share your information with your consent.
        • Storage, retention, and proper destruction of your personal information complies with the 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, and the law.

        Do not hesitate to discuss our policies with any member of our office staff.

        Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

        CHILDREN’S PATIENT FORM

          Has your child ever had any of the following?

          Does your child have or have they ever had any of the following?

          For Parents

          Dental Insurance

          Use your mouse or finger to draw your signature above

          Update medical history

            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.*
            Use your mouse or finger to draw your signature above

            DENTIST REFERRAL

              Please provide specialist with appropriate details of problem; i.e. urgency, areas of concern, using F.D.I. tooth numbering system.
              Indicate any special factors –either dental or medical –such as allergies and medical problems relevant to diagnosis and treatment.


              Date of Referral

              SLEEP APNEA FORM

                Trillium Dental

                Downtown Minto Location Applicable

                Sleep Apnea Form

                Required to fill for next section completion*
                Required to fill for next section completion
                Required to fill for next section completion