Patient Intake Form

Please fill out this form to the best of your abilities. If you have any questions or concerns please don’t hesitate to contact us at (604) 526-1216.

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Personal Information - Step 1 of 6

Personal Information

Please fill this section out in full.

Name

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Layout

Date of Birth

Biological Sex

Male
Female

I authorize contact from ROYAL SQUARE DENTAL via email/text messages (including Appointment Reminders, Product Information and Promotions).

Preferred Method of Contact

Phone
Email
Text Message/SMS

How did you hear about us? (Referral)

Consent to Collect, Use and Disclose Personal Health Information

In accordance with the PIPEDA (Personal Information Protection and Electronic Documents Act).

I authorize Royal Square Dental to collect personal information relating to my dental and medical health. I understand this information is required to allow for proper evaluation, diagnosis and treatment of oral and dental health conditions.

I consent to the communication of information to my referring dentist, other dental specialists, my physician(s), dental laboratories, my dental benefits plan administrator, insurance carrier, and the College of Dental Surgeons of British Columbia when necessary. The information may be transferred to the necessary individuals via phone, email or fax. This information may include clinical records, x-rays, diagnostic models, general health information obtained from medical history review, insurance information, phone numbers, addresses and photographs of my teeth, mouth, smile, and face. Clinical information, photographs and x-rays may also be used for long term follow up and research, as well as for education and teaching purposes.

Royal Square Dental recognizes the importance of personal information protection and makes every effort possible to safeguard this information.

I hereby certify than I have read and understand this document.

Print Name

I hereby certify than I have read and understand this document.

Signature of Patient (Parent or Legal Guardian)

Date Signed

For added security hCaptcha has been added to this form

Patient Intake Form

Personal Information

Insurance Information

Dental History

Medical History

Consent to Treatment and Office Policy

Consent to Collect, Use and Disclose Personal Health Information