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Dr. Yarmand
Dr. Rifkind
Dr. Tocchio
The Team
Back
Patient Forms
Financial Information
Pre-Op Instructions
Post-Op Instructions
Home
About
Dr. Yarmand
Dr. Rifkind
Dr. Tocchio
The Team
Patient Information
Patient Forms
Financial Information
Pre-Op Instructions
Post-Op Instructions
Referral Forms
Procedures
Contact Us
☎ (416) 221-6656
patient forms
patient form
ONLINE FORM
New Patient Forms
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Home Phone
(###)
###
####
Employer:
Work Phone
(###)
###
####
Occupation:
Cell Phone
(###)
###
####
Email
How did you hear about us?
Emergency Contact:
*
Telephone Number
*
(###)
###
####
Referring Dentist:
Telephone Number:
(###)
###
####
Dentist (if different)
Telephone Number
(###)
###
####
PERSONAL INFORMATION AND ELECTRONIC DOCUMENTS ACT
I authorize release to my dental benefit plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.
Date
MM
DD
YYYY
FINANCIAL INFORMATION
Method of payment:
Cash
Credit Card
Debit
Person responsible for financial matters:
Self
Spouse
Parent/Guardian
Other
Primary Insurance
Subscriber:
Date of Birth
MM
DD
YYYY
Insurance Company:
Telephone Number:
(###)
###
####
Policy #
Certificate #
FINANCIAL ARRANGEMENTS
For all appointments, payment is due on the day of your treatment. For your convenience, we welcome VISA, Master Card and direct debit as payment. We will complete any necessary insurance forms for you in order to maximize your reimbursements. If you experience lengthy delays in receiving reimbursement, you should phone the insurance company directly. We try our best to be as accurate as possible in estimating the cost of treatment. However, because of the very nature of surgical procedures, it is sometimes difficult to predict the exact course of surgery and treatment and therefore fees can sometimes change. We need this flexibility in order to provide you with the best quality of care possible. All patients receiving treatment provided with sedation are required to make payment prior to receiving any medications. Our team is here to make processing insurance claims and payments as simple as possible for you and would be happy to answer any questions you may have. I certify by my signature below that I have read and understand the above policy and agree to abide by the terms and conditions outlined therein.
Thank you!
PRINTABLE FORM
medical history form
ONLINE FORM
Medical History
Name
*
First Name
Last Name
Date
MM
DD
YYYY
Do you see a Family doctor regularly?
Yes
No
Do you have any allergies?
Yes
No
If yes, list the allergies, especially to medicine.
Do you take any medications?
Yes
No
If yes, list the medications
Have you ever taken a drug for the treatment of osteoporosis in the last 5 years?
Yes
No
Are you currently taking any vitamins or herbal supplements?
Yes
No
If yes, list the supplements
Women: Are you pregnant?
Yes
No
Do you ever get chest pain?
Yes
No
Do you feequently get fluttering or pounding feeling in your chest?
Yes
No
Do you get short of breath after climbing two flights of stairs?
Yes
No
Do your ankles, feet or hands swell?
Yes
No
Do you bruise easily?
Yes
No
Have you ever had an operation?
Yes
No
Have you ever been in the hospital overnight?
Yes
No
Have you had any problems with anesthesia?
Yes
No
Do you currently smoke?
Yes
No
Do you Vape?
Yes
No
Do you use any Nicotine products such as gum or patches?
Yes
No
Do you get motion sickness in cars or planes?
Yes
No
Do you drink alcohol?
Yes
No
Have you ever had any of the following?
Asthma
Anemia
Artificial Heart Valve
Artificial Joint
Arthritis/Gout
AIDS/ HIV
Bronchitis
Blood Transfusion
Cancer
Cortisone/ Steroid
Diabetes
Drug Addiction
Epilepsy/ Seizures
Emphysema
Glaucoma
Heart Attack
Heart Murmur
Heart Rhythm Disorder
Heart Pacemaker
Hepatitis B / C
Hypertension
Jaundice
Lung Disease
Liver Disease
Mitral Valve Prolapse
Malignant Hyperthermia
Pneumonia
Psychiatric Care
Rheumatic Fever
Sickle Cell Anemia
Stroke
Tuberculosis
Thyroid Disease
Have you had any serious illnesses?
Please include the date
Anything else you would like to tell us?
I understand the preceding questions and I have answered them truthfully and completely.
Thank you for submitting your medical history!
Printable form
