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Patient Forms

Patient Information form

We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any questions we’ll be glad to help you.



Medical History for New Patient



Privacy Cosent Form

Privacy of your personal health information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. In this office, Dr. Pearl Chen is the contact person for personal health information related matters. All staff members who come in contact with your personal health 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. 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 health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of you personal information, we will seek your approval in advance. Your personal health information may be accessed by regulatory authoities 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. You may withdraw your consent for use or disclosure of your personal health information at any time. 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 your information with your consent; storage, retention and destruction of your personal health information complies with 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. How Our Office Collects, Uses and Discloses Patients’ Personal Health Information Our office understands the importance of protecting your personal health 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 personal health information about you for the following purposes: to deliver safe and efficient patient care to identify and to ensure continuous high quality service to assess your health needs to provide health care to advise you of treatment options to enable us to contact you to establish and maintain communication with 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 the 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, to complete and submit dental claims 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 voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of 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 to prepare materials for the Health Professions Appeal and Review Board (HPARB) to invoice for goods and services to process credit card 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 have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance. Your personal health 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. You may withdraw your consent for use or disclosure of your personal health information at any time. Patient Consent I have reviewed the above information that explains how your office will use my personal health information, and the steps your office is taking to protect my information. I agree that Dr. Kiran Kapadia can collect, use and disclose personal health information about the health records set out above in the information about the office’s privacy policies.



Financial Agreement

  • For my convenience, this office may release my information to my insurance company, and receive payment directly from them.
  • I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time.
  • If sent to collections, I agree to pay all related fees and court costs.
  • Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.
  • I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due.
  • I will pay a fee for appointments broken without 24 hours notice.
  • Treatment plans may change, and I will be responsible for the work actually done.