Date of Birth:(required)
Preferred Contact Method:Home PhoneWork PhoneEmailOther Phone
Are you available for Short Notice Appointments?---YesNo
How did you hear about this office?
Drivers License Number or SIN:
Do your gums bleed while brushing or flossing?YesNo
Have you ever had Orthodontic (braces) Treatment?YesNo
Are your teeth sensitive to cold, hot, sweets or pressure?YesNo
Do you feel pain with any of your teeth?YesNo
Do you have any sores or lumps in or near your mouth?YesNo
Have you ever had a head, neck or jaw injury?YesNo
Do you have any loose teeth or have they ever shifted?YesNo
Does food frequently get caught in your teeth?YesNo
Do you bite your lips or cheeks frequently?YesNo
Do you have Headaches or Migraine?YesNo
Have you had any difficult extractions in the past?YesNo
Ever worn a night guard or other appliance?YesNo
Have you ever had difficulty opening or closing jaw?YesNo
Have you had any pain in your jaw area?YesNo
Have you ever had Periodontal Treatment (gums)?YesNo
If you have a current dental problem, please describe:
Please give a brief description of your Oral Hygiene habits:
Do you have any other concerns about having Dental Treatment? YesNo
If so, please explain.
Are you happy with the appearance of your teeth?YesNo
If no, please explain.
Do you ever feel nervous about visiting the Dentist?YesNo
Please enter your previous Dentist name and Location:
Date of your last Dental X-Ray:
Date of your last teeth cleaning:
Date of your Last Dental Exam:
Have you ever been advised to take antibiotics prior to dental treatment?YesNo
Are you currently seeing a Family Physician?YesNo
If so,please enter name, phone number, and address.
Have you ever had a serious head or neck injury?YesNo
Have you recently (in the last two years) been hospitalized or had a major operation?YesNo
Date of your last Physical Exam
Are you pregnant?YesNo
If yes, what is the expected delivery date?
Are you taking birth control medication?YesNo
Artificial Heart ValveYesNo
Head or Neck injuriesYesNo
Heart Pace MakerYesNo
Hepatitis B or CYesNo
High Blood PressureYesNo
Please enter details or any further information.
Please list any prescription or non-prescription medicine you are currently taking or have recently taken:
Barbiturates, sedatives or sleeping pillsYesNo
Do you use any form of Tobacco or are wearing a nicotine patch?YesNo
Are you dependent on Alcohol or drugs?YesNo
If so, have you received treatment?YesNo
Have you ever tested HIV positive?YesNo
Do you bruise easily, or bleed severely when you are cut?YesNo
Do you have severe earaches; ear, throat or sinus infections; or headaches?YesNo
Do you wear eyeglasses or contact lenses?YesNo
If you have ever been advised against taking any type of medication, please list them below.
If you have any allergic conditions please list them below. This can include asthma, hay fever, food allergies, and metal or latex allergies.
Please list any medical conditions or illnesses the child has recently had. This can include Measles, Strep Throat, Tonsillitis.
As you are surely aware, the vast majority of dental services are not covered by Manitoba Health. This means the fees we charge are the sole responsibility of the patient. With this in mind we will do our best to ensure you are aware of the fees for your non-routine treatment prior to initiating such treatment. If you have questions about your routine treatment fees, (eg. cleanings), feel free to ask. In cases where planned treatment exceeds $300.00, or it is questionable whether your insurance benefits will cover the procedure, (eg. crowns), treatment plans with full estimates will usually be provided. Upon patient request, written estimates will be supplied for work under the $300.00 amount.
In many cases our office follows the current Manitoba Dental Association Fee Guide for the fees listed in the guide. Some of our fees may differ from the fee guide as the guide lists average fees and do not always apply due to complexity of treatment or materials being used. There are some fees we charge from the Canadian Dental Association master guide which are not found in the Manitoba Dental Association Fee Guide. These codes are not always recognized by provincial dental plans.
For patients with dental benefits we will submit claims on your behalf and accept assignment of the benefits, where permitted by the benefits plan (some exceptions apply). We will work with you to help you determine what your benefit coverage is, but as each benefit plan is different, even for plans offered by the same company, it is up to our patients to know what their coverage is.
As advancements in dentistry take place, new codes (fees) are added to the fee guide to reflect these changes. However, not all dental plans are up-to-date with providing coverage for these codes, or for providing coverage on the current year's fee guide.
For codes that we routinely have the most trouble with we will often send in a predetermination to your benefits provider to assess the coverage prior to treatment. Please note that these codes often are associated with lab fees and when these predeterminations are returned, the lab fees are often excluded from the benefit provider's calculations.
It is important to note that your dental benefits package is usually provided by your employer. If you have any concerns about the quality of your benefits package, please talk to your employer. When it comes to the utilization of the benefits package you have, we will assist you any way we can.
Our office accepts Master Card, Visa, cheques ($30 NSF charges on all returned cheques), debit, and cash.
Please note we do not accept or provide change when paying with cash. Excess payments will be maintained as a credit on your account and applied to future billings. Please note, rescheduling appointments with less than a full business day's notice, and missed appointments are subject to a short-cancel/no-show fee of $65.00, which is not covered by insurance.
Please note, photos and x-rays taken at My Family Dentist are the property of Dr. Raed Kamal Dental Corporation and may be used for marketing and or educational purposes (patient identification will be removed). Copies are available upon request. A fee for reproduction may be charged for this service.
Name of patient, parent, or guardian:
Subscriber ID #:
I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of and services described to Dr. Raed Dental Corporation and its representatives. This includes but is not limited to the submission of x-rays for claim processing
and gathering of insurance benefit details.
This authorization shall continue in effect until the undersigned revokes the same.
Name of patient, parent, or guardian:
I hereby assign my benefits, payable from claims submitted electronically, to Dr. Raed Kamal Dental Corporation and its representatives and authorize payment directly to it and its representatives.
This Authorization shall continue in effect until the undersigned revokes the same.
file with Dr. Raed Kamal Dental Corporation as updates to insurance information may occur and will not be updated here.