New Patient Intake Form

Preferred Name:
Gender
DD slash MM slash YYYY

Contact

We can communicate via phone, text or email. Please select all preferred contact methods
Would you like to be contacted for short notice appointments?
Address
Emergency Contact

How did you hear about us?

How did you hear about us?

Insurance (If applicable)

Primary:
MM slash DD slash YYYY
Secondary:
MM slash DD slash YYYY
Family Physician
PATIENT CONSENT: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of our office providing you with quality dental care. In this office, Dr. Dan Auprix 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.

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 our information with your consent, storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; our privacy protocols comply with the privacy legislation standards of our regulatory body, the Royal College of Dental Surgeons of Ontario and the law.

By signing the consent section of this Patient Consent Form, you have 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 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 defence of a legal issue.

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature
Name of Patient/Parent/Guardian (print)
MM slash DD slash YYYY
Date
This field is for validation purposes and should be left unchanged.