New Patient Information

In an effort to serve you better, we ask that you complete the following new patient form. We will be glad to assist you with any questions you have.


How did you hear about us?

Your Name:*

Your Address:*

Date of Birth:*

Emergency Contact:*
Phone Number:*
Family Doctor:
Phone Number:


What is the reason for today's visit?  Examination  Cleaning  Emergency  Other:

Are you presently having dental pain?

Is there a dental problem you would like to take care of as soon as possible?

How frequently do you see your dentist?   3-6 months   Annually    Other:  

Previous Dentist  

Date of your last dental visit?  

Last cleaning:  

Full mouth series of X-Ray  

How often do you brush per day? Floss?
Do you feel you have bad breath?

Are your teeth sensitive to:   Hot   Cold   Biting   Sweets

Do your gums bleed when:   Brushing   Flossing   Never  

Do your gums bleed easily?
Do your have bad breath or bad taste in your mouth?

Do you smoke or use any other form of tobacco?

Have you ever had jaw joint surgery?

Do you have pain in your jaw joints or suffer from migraine headaches?

Does any part of your mouth hurt when clenched?
Does your jaw crack or pop when opened widely?

Have you had:   Braces   Oral Surgery   Gum Treatment   Root Canal

Do you have trouble sleeping? Sleep Apnea? Do you snore?
Do you have a night time appliance you wear?
Do you grind or clench your teeth during the day or night?
Have you ever experienced any growths or sore spots in your mouth? If so, where?
Have you ever had any problems with previous dental treatments? If yes, please specify?

Are you satisfied with the appearance of your teeth?

Please list any other dental concerns or questions?

I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.


For Collection Use and Disclosure Information

Privacy of a patient is an important part of our office. We understand the importance of protecting personal information. We are committed to collecting, using, and disclosing your personal information. In this office, Dr. Shasha 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 you disclosed to us. They are all trained in the appropriate uses and protection of your information.

Attached to this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information is collected about you
  • We only share your information with your consent
  • Storage retention and destruction of your personal information complies with every legislation and privacy protection protocols
  • Our privacy protocols comply with privacy legislation standards of our body of the royal college of Dental Surgeons of Ontario, and the law

Do not hesitate to discuss our polices with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensure that you receive the best quality dental care.

How Our Office Collects, Uses and Discloses Patients Personal Information

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information. This office will collect, use and disclose information about you for the following purposes:

  • To deliver safe and efficient patient care
  • To identify and to ensure continuous high quality service
  • To asses your health needs
  • To provide health care
  • To advise you of treatment options
  • To enable us to contact you
  • To establish and maintain communication with you
  • To offer and provide treatment, care and services in the relationship to the oral and maxillofacial complex and dental care generally
  • To communicate with other treating health care providers, including specialist and general dentists who are the referring dentists and/or peripheral dentists
  • To allow us to maintain communication and contract with you to distribute healthcare information and to book and confirm appointments
  • To allow us to efficiently follow-up with treatment care and billing
  • For teaching and demonstrating purposes on an anonymous basis
  • To complete and submit dental claims for third party adjunction and payment
  • To comply with legal and regulatory requirements, including the delivery of patients charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the regulated health protection act.
  • To comply with agreements/undertakings entered voluntarily by the member with the Royal College of Dental Surgeons of Ontario including the delivery and/or review of patients charts and records to the college in a timely fashion for regulatory and monitoring purposes.
  • To permit potential purchasers, practice brokers of advisors to evaluate the dental practice
  • To allow the potential purchasers, practice brokers or advisors to conduct in preparation for a practice sale
  • To deliver your charts and records to the dentist's insurance carrier to enable the insurance company to asses liability and quantity changes, if any
  • To prepare materials for the Health Professionals Appeal and Review Board (HPARB)
  • To invoice for goods and services
  • To process credit card payments
  • To collect unpaid accounts
  • To assist this office to comply with the regulatory requirements
  • To comply generally with the law

By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection use and/or disclosures or 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. You information might be accessed by the regulatory authorized under the terms of the Regulated Health Professionals Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling it's manors under the RHPA, and for the defence of a legal issue. Our office will not under any conditions supply your insurer with your confidential medial history. In this event, at this time, where a request is made, we will forward the information directly to you for review and for your specific consent. When usual 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 review your consent for the use of disclosure of your personal information and we will explain the ramifications of that decision, and the process.

I have reviewed the above information that explains how your office will use my personal information and the steps your office is taking to protect my information. Now that your office has a privacy code, and I can ask to see the code at any time, I agree that Smiles Dental Aurora can collect, use and disclose my personal information as said above about the offices privacy policy.


In order to make your dental visit more convenient, our office offers to bill your insurance directly. We accept different insurance providers. Please contact us for more details!

I have read and understood the above information and had the opportunity to ask questions and receive answers. I understand that responsibility for payment of the dental services for my dependents and myself is mine, and I assume responsibility for fees associated with these services. I authorize Smiles Dental Aurora to receive payment from my insurance company directly.

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