- My Forms at Home

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

Personal Information

How did you hear about our office?

Another Patient

Flyer

Google

Location

Newspaper

Sign

Website

Word of Mouth

If "Another Patient" please specify the name:

Account information

We will submit all insurance claims for you and attempt to collect all insurance benefits you are entitled to. However, we cannot guarantee coverage due to the complexities of insurance contracts. The patient portion and any amounts unpaid by the insurance are your responsiblity.

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Dental History

TMJ

Do you have or have you ever had any of the following? Tick off those that apply.

Medical Questions

Please fill out all the questions to the best of your knowledge. Thank You.

Authorization

To the best of my knowledge, the information provided is correct. I have been informed that my physician(s) may be contacted by letter or phone by the dentist in order to complete the details of my medical history. I hereby consent to my physician providing the dentist with any information in this regard to help ensure safe dental treatment.

I authorize release, to my dental benefits coordination and CDA, of information contained in claims submitted electronically. This authorization shall continue in effect until the undersigned revokes the same.

I hereby assign my benefits, payable from claims submitted electronically, to Dr. Peter Olejarz, and authorize payment directly to him. This authorization shall continue in effect until the undersigned revokes the same.

I hereby certify that I have been notified of the privacy policies of this office, whom to contact regarding privacy concerns and how to request further information.