Why do I need to fill out the clinical intake form?

The clinical intake form collects essential medical history, current symptoms, and contact information to ensure your dental hygiene treatment is safe, personalized, and tailored to your health needs.

When should I complete the clinical intake form?

It is recommended to complete and submit your clinical intake form online prior to your appointment at Smile Care Studio to save time and streamline your check-in process.

Is my personal and medical information secure?

Yes, all information submitted through our clinical intake form at Smile Care Studio is handled with strict confidentiality and privacy standards in accordance with applicable healthcare regulations.

Where is Smile Care Studio located?

Smile Care Studio is located at 1480 Walsh St W, Thunder Bay, Ontario, Canada, with free parking available at the door.

Clinical Intake Form | Smile Care Studio Thunder Bay

Section 1

Patient Contact Information

Full Name *

Date of Birth *

Address including Postal Code *

Contact Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone Number *

Section 2

Medical History Section

Section 2

Medical History Section

Last Dental Examination/ Cleaning

Name of current / Previous dental office if available

Any Dental/ Oral Concern

Section 3

Insurance Information

Do you have Dental Insurance? *

Name of Insurance Company

Plan / Group Number

Member / Policy Number

Certificate / Identification Number

Primary Policy Holder Name

Relationship to the Subscriber

Primary Policy Holder Date of Birth

Insurance Phone Number

Secondary Insurance Company

Secondary Insurance Plan / Group Number

Secondary Member / Policy Number

Secondary Policy Holder Name

Secondary Relationship to Subscriber

Section 4

Patient Consent and Acknowledgement

Authorization and Release *

I certify that I have read and understand the above questions to the best of my knowledge and the above questions have been accurately answered. I understand that providing incorrect or withholding information can be dangerous to my health. I authorize the dental hygienist to release any information including the Dental Hygiene diagnosis and the records of any treatment or examination rendered to the named client during the period of such Dental Hygiene care to third party payers and/or health practitioners for insurance and health-related referral purposes only. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize payment directly to the Noreen Khan, RDH with Smile Care Studio from any group insurance benefits otherwise payable to me. I understand my personal information is collected, used, and stored in a professional and responsible manner according to PIPEDA/PHIPA standards and Smile Care Studio's privacy policy. I understand that payment is due in full after treatment is rendered (unless prior arrangements have been approved). I give consent for dental hygiene treatment on my behalf (or my dependent) and understand that the specific risks, benefits, and post care instructions will be provided by the dental hygienist during the relevant course of the appointment. Additional written informed consent may be required for complicated or special procedures. I understand that any questions I may have regarding any treatment should be brought forth to be answered and addressed by the dental hygienist.*

Yes, I consent

No, I do not consent

Thank you for taking the time to fill out this form for Smile Care Studio- Noreen Khan, RDH Please email at [email protected] when you have completed this form, to ensure your appointment is booked. Please add completed. *

Completed

Patient Clinical Intake Form

Patient Clinical Intake Form

Complete your Client Intake Form

Patient Contact Information

Medical History Section

Medical History Section

Insurance Information

Patient Consent and Acknowledgement