Patient Information

    Dr. Manisha Chauhan, DDS

    2160, 4 Royal Vista Way NW

    Calgary, AB T3R 0N2

    587-358-2160[email protected]

    (This number will be used for confirmation of appointments)

    (Email will be used for electronic communication)

    PREFERRED METHOD OF CONTACT

    How did you hear about us?

    ( Please Select One )

    Referred Name

    DENTAL QUESTIONNAIRE

    Previous dentist name or dental office :

    When was your last dental visit :

    When were your last x-rays taken :

    When was your last dental cleaning :

    Are you currently in any discomfort/pain with your teeth or gums?

    Do your gums ever bleed?

    Have you ever fainted or had complications following dental treatment?

    Have you ever had an injury, surgery, or x-ray therapy to the face or jaw?

    Do you have any pain in your jaw?

    Are you currently in any discomfort/pain? There should be box to explain

    Do you clench or grind your teeth?

    Would you like to have straighter teeth?

    Are you interested in having ZOOM Whitening treatment?

    Nervous or anxious about dental treatment?

    Desired outcomes after dental treatment :

    MEDICAL QUESTIONNAIRE

    (Please check all that apply to you)

    PREGNANT

    WEEK

    Do you require PREMEDICATION such as an antibiotic for dental treatment due to a heart condition and/or artificial joints?

    Do you have ALLERGIES to?

    ANTIBIOTIC (please specify)

    SPECIFIC FOOD

    OTHER

    Have you been admitted to a hospital for major surgery in the last 2 years?

    Please list all the medications, pills, vitamins or herbs you are presently taking:

    For

    For

    For

    For

    For

    Financial Policies for Dental Patients

    Your dental insurance policy is an agreement between you and your insurance company, and we will be happy to assist you in preparing and sending in the necessary forms. Please remember that no insurance company attempts to cover all dental costs. We cannot render dental treatment on the assumption that our dental fees will be paid in full by an insurance company. Full payment to our office remains your responsibility, regardless of how much your insurance does or does not pay.

    I am aware that Avyan Family Dental direct bills my insurance company as a courtesy to me and that in doing so, the dental office accepts no responsibility for any uncovered amounts, amounts over benefit maximums, limitations or plan restrictions, etc. I understand that the dental office collects my dental coverage information as a guideline only to assist me in maximizing my benefits and this does not hold them responsible for my dental account. Avyan Family Dental advises that I make myself aware of my dental plan and eligible coverage and that I ask my dental team about all procedures I am authorizing.

    Avyan Family Dental advises me to contact my plan administrator or insurance company for questions regarding eligible procedures and authorization of treatment. In addition, I am advised to make myself aware of all costs involved with my dental care. Avyan Family Dental advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan.

    Payment is due at the time of service. I am aware that if the dental office does not receive confirmation from my insurance for their exact payment, then Avyan Family Dental will charge the credit card I agree to leave on file when payment is paid to the office by my insurance company, whenever that date may be.

    I also understand that any uncovered procedures that may have been done at another dental office are my responsibility. IMPORTANT: Please be advised that complete oral examinations (new patient exams) & x-ray coverage will be denied by your insurance if you have had this procedure completed at another dental office within the time limitations on your specific plan. You are responsible for this payment then in our office should this not be an eligible benefit with your coverage.

    I agree to the financial responsibility for any amounts not covered by my dental insurance to be applied to credit card below:

    Credit Card (Circle one:)



    Avyan Family Dental Personal Information Consent Form - Privacy Act Information

    We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances in this form, we also collect, use and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, home/cell telephone numbers, and e-mail addresses. (Collectively referred to as “Contact Information”.) Contact information is collected and used for the following purposes:

    • To open and update patient files

    • To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts

    • To process claims for payment or reimbursement from third party health benefit providers and insurance companies

    • To send reminders to patients concerning the need for further dental examination or treatment

    • To send patients informational material about our dental materials

    • To follow up with treatment and/or customer services

    Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient's behalf. Financial information may be collected in order to decide for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as "Medical Information".) Patients' Medical information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients' Medical Information is disclosed for the following purposes:

    • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf

    • To other dentists and dental specialists where we are seeking a second opinion and the patient has consented to us obtaining the second opinion

    • To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment

    • To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion

    • To other health care professionals, such as physicians, if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment

    If we are ever considering selling all or part of our dental practice, qualified, potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

    Dentists are regulated by the Alberta Dental Association and College, which may inspect our records and interview our staff as part of its regulatory activities in the public interest.




    Changing an Appointment:

    • If you are unable to keep your appointment, please notify us as soon as possible so that we may accommodate another patient.

    • We require at least 2 business days before your scheduled visit to avoid a missed appointment fee of $80.00.