Patient Intake Form

Please complete this form before your appointment. Your health information is encrypted and protected in compliance with healthcare privacy laws.

Your Privacy is Protected

All health information submitted through this form is encrypted using AES-256 encryption before transmission and storage. We comply with PHIPA (Personal Health Information Protection Act) and PIPEDA (Personal Information Protection and Electronic Documents Act).

Why We Need This Information

  • Medical History: To identify conditions that may affect your dental hygiene treatment
  • Medications: To avoid potential interactions and take necessary precautions
  • Allergies: To ensure we don't use any products that could cause a reaction
  • Dental History: To provide personalized care and address your specific concerns

Patient Intake Form

Please complete this form before your appointment. Your information is encrypted and stored securely in compliance with PHIPA and PIPEDA regulations.

Your Privacy is Protected

Your health information is encrypted and stored securely in compliance with PHIPA and PIPEDA regulations. Only authorized staff can access your information.

Personal Information
Medical History
Dental History
Consent

Consent for Treatment

I consent to the collection and use of my personal health information for the purposes of receiving dental hygiene treatment. I understand that my information will be kept confidential and secure in accordance with PHIPA and PIPEDA regulations.

View our Privacy Policy

Prefer to Complete This Form In Person?

If you prefer, you can complete the intake form when our hygienist arrives for your appointment. Please note this will add approximately 10-15 minutes to your appointment time.

Questions? Contact us at (514) 431-1999 or [email protected]