LANDING PAGES FORMS

Patient's Name*

Landing Page Form


Contact Our Ottawa Dentists


get in touch with us form


Sleep Apnea

Please check the box that best relates to your symptoms.
Required to fill for next section completion*
(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.*
Required to fill for next section completion
Required to fill for next section completion
Required to fill for next section completion*
Please submit your first and last name below. Both are required.*
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DENTIST REFERRAL

Periodontist Referral
Reason for periodontist referral:
IV Sedation Referral
Reason for IV sedation referral:
Orthodontist Referral
Reason for orthodontist referral:
We are introducing:
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Appointment*
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.
Digital Radiographs*
Radiographs
Select all that applies
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CHILDREN’S PATIENT FORM

Patients Name
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Address
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Parent Name
Please check any of the following that apply:

Has your child ever had any of the following?

Checkbox

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

Please check any of the following that apply:

For Parents

Dental Insurance

Parent Name ( required for under 18 years )
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PATIENT CONSENT FORM

Name of Guardian*
Patient Name*
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By signing the consent section of this patient consent form, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval 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 Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of 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 your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.
Use your mouse or finger to draw your signature above.
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COVID-19 SCREENING FORM

Are you a current or new patient?*
Patient Name*
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Time
:
Question 1: Did you receive your final (or second) vaccination dose more than 14 days ago?*
* 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).
Question 2: Do you have any of the following symptoms?*
Question 3:Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Question 4: Have you travelled outside of Canada in the past 14 days?
Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
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REQUEST AN APPOINTMENT

REQUEST AN APPOINTMENT

Patient's Name*

Contact form 1

Patient's Name*