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?
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:
Date of your last dental visit?
Full mouth series of X-Ray
Are your teeth sensitive to: Hot Cold Biting Sweets
Do your gums bleed when: Brushing Flossing Never
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?
Have you had: Braces Oral Surgery Gum Treatment Root Canal
Are you satisfied with the appearance of your teeth?
Please list any other dental concerns or questions?
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:
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:
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.
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!
15213 Yonge St, Suite 6
Meet the Team