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604-457-2266
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Dr. Reza Aran
Dr. Asef Karim
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Pitt Meadows Orthodontics
Physician/Dentist Information
Postal Code
*
Dental Insurance Plan #2
Check any conditions that apply
Heart murmur/heart disease/heart attack
Stroke
Kidney/liver disease
Arthritis
Asthma/COPD
Epilepsy
Seizures
Cancer
Radiation Treatment
Mental Illness
Autism
Special Needs
Diabetes
Severe Allergies
High Blood Pressure
Hepatitis
Rheumatic Fever
Sinus Trouble
Bleeding Disorder
HIV
Tuberculosis
Fainting
Hearing Impairment
Covid-19
Other not listed
Insurance Company Name (Dental Insurance Plan #2)
For minor patient
Consent for Care
9. (Women) Are you pregnant now?
*
Yes
No
Emergency Contact #
Policy Holder Date of Birth (Dental Insurance Plan #1)
Policy Holder Name (Dental Insurance Plan #2)
Last Name
*
Parent's Adress (if patient is minor)
COVID-19 Questionnaire
Sex
*
Male
Female
Other
Parent's Postal Code (if patient is minor)
Parent's First Name (if patient is minor)
Final Confirmation
*
I confirm all information provided above is accurate and complete to the best of my knowledge.
14. Fever (defined as above 38°C)?
*
Yes
No
17. Muscle aches?
*
Yes
No
Patient Name (Consent for Care):
*
Parent's Last Name (if patient is minor)
Email
*
I authorize examination/treatment from Pitt Meadows Orthodontics including the use of radiographs (X-rays), the administration of anesthetics, as may be recommended for my treatment. I also authorize the taking of images (including for example photographs, radiographs and films) and the creation of any other records (electronic and/or hardcopy) for the purpose of treatment, teaching, presentations, publications, research, or marketing. I understand that the records will be anonymous in order to protect my identity. Further, if applicable, I authorize Pitt Meadows Orthodontics to release the required records to my dental insurance provider(s) in order to submit a pre-determination for treatment, and to receive payment from the insurance provider for services rendered.
*
I confirm that I am the legal guardian of the person listed above.
16. Chills?
*
Yes
No
Date of Last Dentist Visit
Physician's Phone #
3. Are you taking any medication or drugs (if yes, please list below)?
*
Yes
No
Date of Birth
For minor patient, name of parent/legal guardian:
Supplemental Informed Consent for Orthodontic Treatment in the Era of Covid-19. Thank you for your trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 also known as “Coronavirus”, at any time or in any place. Be assured that we have always followed provincial regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our clinic, just as you might be at you’re your gym, grocery store or favorite restaurant. “Physical Distancing” has reduced the transmission of the Coronavirus. Although we have taken measures to provide distancing within our practice, due to the nature of the procedures we provide, it is not possible to maintain physical distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
*
Although exposure is unlikely, I accept the risk and consent to treatment
11. Dry Cough?
*
Yes
No
Cellphone
*
I.D./Cert # (Dental Insurance Plan #1)
Other condition that is not listed above:
Main concerns for your upcoming appointment
First Name
*
Mother's Name (if patient is a minor)
New Patient Form
Address
*
Insurance Company Name (Dental Insurance Plan #1)
12. Sore throat or painful swallowing?
*
Yes
No
Father's Phone #
Policy Holder Date of Birth (Dental Insurance Plan #2)
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
2. Have you been under the care of a physician during the past 2 years for a medical condition?
*
Yes
No
Policy Holder Name (Dental Insurance Plan #1)
Group/Policy/Plan # (Dental Insurance Plan #2)
5. Have you been diagnosed with ADHD or ADD?
*
Yes
No
13. Shortness of breath?
*
Yes
No
Home Phone
19. Fatigue?
*
Yes
No
6. Have you ever experienced unexplained shortness of breath or chest pains?
*
Yes
No
1. Have you ever been a patient in hospital during the past 2 years?
*
Yes
No
7. Have you ever experienced excessive bleeding that required special treatment?
*
Yes
No
Dental Insurance Plan #1
10. Previous Orthodontic Consult?
*
Yes
No
Parent's Email (if patient is minor)
Parent's City (if patient is minor)
I.D./Cert # (Dental Insurance Plan #2)
Father's Name (if patient is a minor)
8. Have you ever had any of the following conditions (if yes, please list below)?
*
Yes
No
How did you hear about Pitt Meadows Orthodontics?
*
Your dentist
A current/past patient
Google/website
Word of mouth
Other
List of Allergies
City
*
List of Medication
4. Are you allergic to latex, penicillin or any other drugs or medications (if yes, please list below)?
*
Yes
No
Mother's Phone #
Medical History
20. Have you had close contact or been in isolation with a suspected Covid-19 case in the past 14 days?
*
Yes
No
18. Headache?
*
Yes
No
Family Physician
Family Dentist
Group/Policy/Plan # (Dental Insurance Plan #1)
15. Loss of appetite?
*
Yes
No
Emergency Contact Name
Additional Email for Appointment Reminders
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