Call Us for Further Info:

519-787-8088

Email Us for Any Question:

info@dentistryontower.com

Visit Us for a Consultation or Second Opinion:

390 Tower Street South, Fergus

Ontario N1M 2P6

Office Hours:

Mon: 9-6 | Tues: 9-6 | Wed: 10-3 |
Thur: 9-6 | Fri: 9-6 |
Sat: 10-3 | Sun: Closed

Make an Appointment

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New Patient Registration Form

(5907272) New Patient Form

PERSONAL INFORMATION * (Required)

* Instructions:

  1. The fields marked by star (*), are required and must be filled out.
  2. If you have any question or need clarification regarding the form, please do not hesitate to call our office at 519-787-8088.
  3. Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.

EMERGENCY INFO

FINANCIAL INFO

PATIENT INFORMATION

DENTAL INSURANCE INFORMATION

Primary Insurance:

Secondary Insurance:

MEDICAL HISTORY * (Required)

PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION * (Required)

 

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 dental centre 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 necessary information is collected about 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.

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

HOW OUR OFFICE COLLECTS, USES & DISCLOSES PATIENTS' PERSONAL INFORMATION * (Required)

 

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 access your health needs.
  • To provide health needs.
  • To advise you of treatment options.
  • To establish and maintain communication with you.
  • To enable us to contact you.
  • To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally.
  • To communicate with other treating health care providers, including specialists and general dentists who are referring dentists and/or peripheral dentists.
  • To allow us to maintain communication and contact with you to distribute health-care information and to book, and confirm appointments.
  • To allow us to efficiently follow-up for treatment, care and billing
  • For teaching and demonstrating purposes on an anonymous basis.
  • To complete and submit dental claims, and estimates for third party adjudication 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 Professions Act.
  • To comply with agreements/undertakings entered into voluntary by the member with the patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes.
  • To permit potential purchasers, practice brokers or advisors to evaluate the dental practice.
  • To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale.
  • To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages if any should occur.
  • To prepare materials for the Health Professions Appeal and Review Board (HPARB)
  • To invoice for goods and services.
  • To process credit card, cash and personal cheque payments.
  • To collect unpaid accounts.
  • To assist this office to comply with all regulatory requirements.
  • To comply generally with the law.
 

By signing the consent section of this patient consent form, you agreed 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 if 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.

PATIENT CONSENT * (Required)

 

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 all of my personal and confidential information. I agree that Family & Cosmetic Dentistry can collect, use and disclose personal information as set above in the information about the office’s privacy policies.

Patient/Parent/Guardian Signature *

Please sign using your finger, mouse, or stylus.

Dentist Signature:

Date:

* Notes:

  1. Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.
  2. If you’ve not filled any required field, form will not be submitted and required fields will be shown in red to be filled.
  3. If you’ve filled all required fields, a confirmation message will be show.

Book an Appointment

Thank you for taking the time to select your preferred day and time.  Please be advised that all requested times are not firm appointments and will be reviewed by Dentistry on Tower.  We will contact you to schedule an appointment.

Dentistry on Tower - Book Appointment form

Office

390 Tower Street South, Fergus, Ontario N1M 2P6