New Patient Questionnaire
Welcome to Mint Leaf Dental and thank you for choosing us!
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  • EMERGENCY CONTACT

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  • FAMILY DOCTOR

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  • MEDICAL HISTORY

  • CURRENT MEDICATIONS

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  • ALLERGIES

  • DENTAL HISTORY

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  • Privacy Information: For Collection, Use and Disclosure of Peronsal Information

    Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.

    In this office, Dr. Alexandra Ociepa acts as the Privacy Information Officer.

    All team members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

    Below, we have outlined what our office is doing to ensure that:
    -only necessary information is collected about you;
    -we only share your information with your consent;
    -storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
    -our privacy protocols comply with privacy legislation, standards of our regulatory body, 
the Royal College of Dental Surgeons of Ontario, and the law.

    Do not hesitate to discuss our policies with Dr. Alexandra Ociepa or any member of our office team.
  • How Our Office Collects, Uses and Discloses Patients' Personal Information

    This office will collect, use and disclose information about you for the following purposes:

    -to assess your health needs and provide safe and efficient dental care
    -to identify and to ensure continuous high quality service
    -to advise you of treatment options
    -to enable us to contact you and maintain communication with you to distribute health care information and to book and confirm appointments
    -to communicate with other treating health care providers, including other dentists, specialists, physicians, pharmacists and lab technicians.
    -to allow us to efficiently follow-up for treatment, care and billing
    -for teaching and demonstrating purposes on an anonymous basis
    -to complete and submit dental claims for third party adjudication and payment
    -to comply with legal and regulatory requirements
    -to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
    -to invoice for goods and services
    -to process credit card payments
    -to collect unpaid accounts
    -to assist this office to comply with all regulatory requirements
    -to comply generally with the law
  • Patient Consent

    I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical question.

    I authorize Dr. Alexandra Ociepa and her team to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.

    I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I consent to the collection, use and disclosure of my personal information by Mint Leaf Dental as set out above in the information about the office's privacy policies.

    In compliance with Canadian Anti-Spam Laws, I understand that by signing this form, I give Mint Leaf Dental permission to send me information such as appointment reminders/confirmations, follow-up, news and events. I can opt-out from these emails at anytime by notifying any of the team members at Mint Leaf Dental.
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  • IMPORTANT INFORMATION:

    Please note that if a proper signature is not provided, a new form will have to be completed from the beginning. Please ask us if you have any questions or concerns.
  • DENTAL INSURANCE:

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