CVOS Oral Surgery – Office Admission Form – Credit Valley Oral Surgery

PLEASE NOTE: Procedures in this Office are NOT a benefit of OHIP.

Today's Date (MM/DD/YYYY):

Preferred Title:

Age:

Date of Birth (MM/DD/YYYY):

Full Name: *

First

Last

Preferred Name:

Address:

Apt #:

City:

Province:

Postal Code:

Home #:

Cell #:

Email

Health Card or Driver's License #:

Expiration Date (MM/DD/YYYY):

Work #:

Name of Spouse / Next of Kin: (Husband, Wife, Names of Both Parents)

Name: *

First

Last

Relationship:

Home / Cell / Work #:

Ext:

Name:

First

Last

Relationship:

Home / Cell / Work #:

Ext:

Power of Attorney:

Yes
No

Name: *

First

Last

Phone #:

Who is the person responsible for payment of your account?

Do you have Dental Insurance?

Yes
No

If yes, please fill in the CDAnet Form.

CDAnet Form

Who referred you to this office?

Dentist
Orthodentist
Medical Doctor
Other

Referrer's Practitioner Name: *

First

Last

Referrer's Practitioner Phone #:

Referrer's Practitioner City Address:

Patient Consent Form: For Collection, Use and Disclosure of Personal Information

Privacy and Anti-Spam Code for CVOS Oral Surgery

The Personal Health Information Protection Act, 2004 (PHIPA) came into effect on November 1, 2004, and governs the collection, use, and disclosure of Personal Health Information within Ontario's health care system, and the Personal Information Protection and Electronic Documents Act, which came into effect in 2001, governs Personal Information other than Personal Health Information.

In addition, Canada's anti-spam legislation came into effect on July 1, 2014. Canada's anti-spam legislation regulates how businesses and individuals communicate electronically.

We collect Personal Information about our patients directly from the patient or from the person acting on their behalf. Occasionally, we collect Personal Information about a patient from other sources if we have obtained the patient's consent to do so or if the law permits.

Privacy of Personal Information is an important principle in the provision of quality care to our patients. We understand the importance of protecting your Personal Information. We are committed to collecting, using and disclosing your Personal Information responsibly and in accordance with the law. We also try to be as open and transparent as possible about the way we handle your Personal information.

This Office has developed this Privacy and Anti-Spam Code (this "Code") to provide a general description of our information and communication practices, how to obtain access to your Personal Information, how to amend incorrect information, and how to make a complaint to our Office or the Information and Privacy Commissioner. As the rules governing the collection, use, and disclosure of Personal Information may change, our practices will evolve and adapt in response to such changes and this Code may be amended from time to time as a result thereof.

I agree that Credit Valley Oral Surgery can collect, use and disclose personal information as outlined above in the office’s policies.

I would like appointment reminders by:

Email
SMS
Phone

Phone #

Patient or Substitute Decision Maker Printed Name:

Witness Printed Name:

Date (MM/DD/YYYY) *

You will be asked to sign upon arrival.