Welcome Package
Please complete this form before your appointment.
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Consent to Receive Emails
I understand by giving my email address and cell phone number to Dr. Tawil Dentistry I agree to receive email and or text message reminders for future appointments along with eNewsletters and promotions. I also understand to cancel or change, an appointment date and/or time can only be done by telephone with a minimum of two business day notice.

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I agree to receive emails from Dr. Tawil Dentistry *
Welcome
In an effort to serve you better, we would ask that you complete the following. We will be glad to assist you.
Please  fill out this form before your appointment.
Patient Information
A parent or guardian will be responsible for decisions on my treatment
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Date *
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Patient Full Name *
Street Address and Unit No. *
City and Province
Postal Code
Date of Birth *
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Primary Telephone Number *
Work Telephone Number *
Family Doctor
Family Doctor Telephone Number
Financial Information
Financial Information - Method of Payment *
Primary Insurance
Name of policy holder (if different from patient)
Date of Birth of Policy Holder
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Insurance Company
Insurance Company Telephone Number
Policy Holder
Insurance year End
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Policy Number
ID / Certificate Number
Maximum Coverage
Percentage Coverage For Basic, Major Restorative, Orthodontic:
Secondary Insurance (if applicable)
Secondary Insurance Policy Holder Name
Secondary Insurance Company Name
Date of Birth of Secondary Policy Holder
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Secondary Insurance Policy Number
Secondary Policy ID / Certificate Number
Secondary Insurance Company Telephone Number
Secondary Insurance Policy Maximum Coverage
Percentage Coverage For Basic, Major Restorative, Orthodontic:
General Release
I, the undersigned. understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental
office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.
My Name *
Date
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Medical History
I, the undersigned. understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental
office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.
Are you presently under the care of a physician? *
Are you presently under the care of a physician? If so, explain:
Have you ever been hospitalized? *
Have you ever been hospitalized? Please explain:
Are you taking any drugs or medication at this time? *
Are you taking any drugs or medication at this time? Please list them:
Have you ever had any adverse effect to any of the following: *
Required
Have you ever been warned against using any other medications? *
Have you ever been warned against using any other medications? Which?
Do you suffer from any allergies (hay fever, latex etc.)? *
Do you suffer from any allergies (hay fever, latex etc.)? Which?
Do you bruise easily or have prolonged bleeding? *
Do you smoke? *
If you smoke - How much per day?
Do you use marijuana recreationally ? *
Have you ever fainted. had shortness of breath or chest pains? *
Women: Are you pregnant?
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Women: Are you using birth control?
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Women: Have you reached menopause?
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Do you have or have you ever had any of the following? Please check appropriate boxes. *
Required
CHILDREN Have you recently had any of the following ?
CHILDREN If you answered YES to the above, when did you have them?
Dental History
What is the reason for today's visit? *
If Other, what was the reason?
How frequently do you see a dentist? *
If Other, what was the reason?
When was your last dental visit?
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How often do you brush per day?
Do you:
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How often do you floss?
Are your teeth sensitive to: *
Do your gums bleed when: *
Do your gums feel swollen or tender? *
Do you suffer from Dry Mouth? *
Do you have bad breath or a bad taste in your mouth? *
Do your jaws crack, pop or grate when you open widely? *
Do you grind or clench your teeth? *
Do you have food catch between your teeth? *
Have you ever had local anaesthetic (freezing)? *
Any complications from anaesthetic (freezing)? *
Have you ever had any problems with previous dental treatments? *
Have you ever had any problems with previous dental treatments? Please specify
Have you ever had any of the following:
Are you happy with your smile? *
If you're not happy with your smile, why?
PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOURE OF PERSONAL 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. Jawad Tawil acts as the Privacy Information Officer.

All staff 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.

Attached to this consent form 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 me or any member of our office staff.
Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.

HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENTS' PERSONAL INFORMATION

Our office understands the importance of protecting your personal information. To help you understand
how we are doing that, we have outlined here how our office is using and disclosing your information. This office will collect
use and disclose information about you for the following purposes:
• To deliver safe and efficient patient care
• To identify and to ensure continuous high quality service
• To assess your health needs
• To provide health care
• To advise you of treatment options
• To enable us to contact you
• To establish and maintain communication with you
• To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care
generally
• To communicate with other treating health-care providers, including specialists and general dentists who are the referring
dentists and/or peripheral dentists
• To allow us to maintain communication and contact with you to distribute health-care information and to book and confirm
appointments
• To allow us to efficiently follow-up 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, including the delivery of patients' charts and records to the Royal
College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated
Health Professions Act
• To comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental
Surgeons of Ontario, including the delivery/and or review of patients' charts and records to the College in a timely fashion for
regulatory and monitoring purposes
• To permit potential purchases, practice brokers or advisors to evaluate the dental practice
• To allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
• 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 prepare materials for the Health Professions Appeal and Review Board (HP ARB)
• 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

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHAP) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPS and for the defense of a legal issue.

Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a
request is made, we will forward the information directly to you for review and for your specific consent.
When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such release is inappropriate. You may with withdraw your consent for use or disclosure of your personal information and we will explain the ramifications of the decision and the process.
PATIENT CONSENT
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 Privacy Code and I can ask to see the Code at any time.

I agree that, Dr. Jawad Tawil, can collect, use and disclose my personal information as set out above in the information about the office's privacy policies. *
Agreed to on date: *
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Good Health to All, Dr. Jawad Tawil and Team
A copy of your responses will be emailed to the address you provided.
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