Medical History/Consent Form

I, the undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive any questions regarding my medical /dental history.

Should there be any change in either my health status or any other information I have provided, I will advise the dental hygienist. I authorize the provider to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment.

I understand that information provided from, or to, my medical doctor or another health provider may be necessary. This office has a privacy policy that protects my personal information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

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 Julia Toth, RDH with Toth Dental Hygiene 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 Toth Dental Hygiene’s privacy policy. My dental hygiene services are rendered according to the standards of infection control mandated by the CDHO.
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.

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