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30 Bertrand Ave Unit B110, Scarborough, ON M1L 2P5, Canada
(647) 490-6888
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Dental Clinic for Ryerson University Students
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Before & After
Our Team
Dr. Reza Barimani
Contact
Home
Services
Cosmetic Dentistry
Dental Implants
Dental Implant Cost
Dental Veneers
Porcelain Veneers
Composite Fillings
Teeth Whitening
Invisalign
Dentures
Dental Cleaning
Orthodontics
Dental Bonding
General Dentistry Toronto
Root Canal Treatment
Dental Fillings
Dental Crowns
Dental Bridges
Sedation Dentistry
Wisdom Teeth Extraction
Teeth Restoration
Pediatric Dentist
Children Dentistry
Gum Graft
Bone Grafting
Walk-in Dental Clinic
Emergency Dentist in Scarborough
Family Dentist
CDCP
Student Discount
Dental Clinic for George Brown College Students
Dental Clinic for Ryerson University Students
Dental Clinic for Seneca College Students
Dental Clinic for York University Students
Dental Clinic for University of Toronto Students
Dental Clinic for Centennial College Students
Before & After
Our Team
Dr. Reza Barimani
Contact
Book Appointment
Now Welcoming New Patients with Canadian Dental Care Plan
(CDCP)
Benefits.
New Patient Form
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New Patient Contact Information
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Step
1
of 9
Title
Mr.
Miss.
Mrs.
Ms.
Name:
First
Last
Date of Birth
Home Address
City and Postal Code
Home Tel
Home Cell:
Email
Occupation
Work Tel:
Who Referred You To Our Office?
Next
In Case Of Emergency, We Should Notify:
First
Last
Relationship
Phone
Name of Family Doctor?
First
Last
Phone (Family Doctor)
Name Of Medical Specialist?
First
Last
Phone (Medical Specialist)
Area of Speciality
Previous
Next
Name of Insured (if different from above):
First
Last
Relationship
Insurance Company
Date of Birth of Insured
Policy/Group Number
Certificate ID Number
Division Number
Do you have a Secondary Insurance?
No
Yes
SECONDARY INSURANCE INFORMATION
First
Last
Relationship
Insurance Company
Date of Birth of Insured
Policy/Group Number
Certificate ID Number
Division Number
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Next
I would like my insurance provider to submit direct payment to Golden Mile Dental and I will pay any outstanding balances.
I would like to PAY IN FULL and have my insurance provider to submit direct payment to myself (Insured).
Next
I understand that Golden Mile Dental (Dr. Nazli Sheibani Dentistry) has invested in the technology to submit my claims electronically. I authorize release, to my dental benefit carrier, information contained in claims submitted electronically.
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Please sign here
First
Last
Current Date
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Next
In order to comply with Canada Anti- Spam Legislation, it is mandatory that we obtain your permission in order to continue any correspondence electronically. Know that we are committed to protecting your electronic information. You can unsubscribe or “opt out” at any given time by contacting us. Our office would like to have your consent to send Email/Text appointment reminders, notifications, and occasionally surveys and important newsletters from Dr. Nazli Sheibani & Golden Mile Dental.
Yes, I consent to receiving all communication as listed above from Dr. Nazli Sheibani & Golden Mile Dental.
No, I do not wish to receive any communication as listed above from Dr. Nazli Sheibani & Golden Mile Dental.
Current Date
Signature
Clear Signature
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Previous
Next
Are you currently being treated for any medical condition or have you been treated within the past year?
Yes
No
Not Sure/Maybe
If yes, please explain
When was your last dental checkup?
Has there been any change in your general health in the past year?
Yes
No
Not Sure/Maybe
If yes, please explain
Are you taking any medication, non-prescription drugs or herbal supplements of any kind?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have any allergies?
Yes
No
Not Sure/Maybe
If yes, please categorize below
Medications
Latex/Rubber Products
Other (e.g. hay fever, seasonal/ environmental, food)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had asthma?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had a replacement or repair of heart valve, an infection of heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease)? Or a heart transplant?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have a prosthetic or artificial joint?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure/Maybe
If yes, please explain
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have a bleeding problem or bleeding disorder?
Yes
No
Not Sure/Maybe
If yes, please explain
Have you ever been hospitalized for any illnesses or operations?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you have or have you ever had any of the following? Please check.
Chest Pain
Heart Attack
Heart Murmur
Stroke,TIA
Rheumatic fever
Mitral valve prolapse
Tuberculosis
Cancer
Pacemaker
Lung disease
Stomach ulcers
Arthritis
Steroid therapy
Diabetes
Thyroid disease
Drug/alcohol/cannabis use or dependency
Seizures(epilepsy)
Kidney disease
Shortness of breath
Osteoporosis medications (e.g. Fosamax, Actonel)
Are there any conditions or disease not listed above that you have or have had?
Yes
No
Not Sure/Maybe
If yes, please explain
Are there any disease or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you smoke or chew tobacco products?
Yes
No
Not Sure/Maybe
If yes, please explain
Are you nervous during dental treatment?
Yes
No
Not Sure/Maybe
If yes, please explain
Are you breastfeeding or pregnant? What is the expected delivery date?
Yes
No
Not Sure/Maybe
If yes, please explain
Do you identify as a patient with disability)?
Yes
No
Not Sure/Maybe
If yes, please explain
Previous
Next
What is the reason for your visit today? Are you currently experiencing any dental problems?
Have you been seeing a dentist regularly?
Yes
No
If No, please explain
Are you nervous during dental visits?
Yes
No
Have you had a bad experience or complications during dental treatment?
Yes
No
When was your last dental visit? What was done at the appointment?
When did you last have dental X-rays?
How often do you brush your teeth? How often do you floss? Do your gums bleed when you brush or floss?
Have you been told to take antibiotics before a dental appointment?
Yes
No
Not Sure/Maybe
Do you feel that you have bad breath?
Yes
No
Not Sure/Maybe
Are you happy with the appearance of your teeth?
Yes
No
Not Sure/Maybe
Do you have any problems with your jaw (clicking, limited movement, pain)?
Yes
No
Not Sure/Maybe
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?
Yes
No
Not Sure/Maybe
Previous
Next
Patient/parent/Guardian Name
First
Last
Current Date (Patient/parent/Guardian)
To the best of my knowledge, the information I provided is correct: (Patient/parent/Guardian Signature)
Clear Signature
Patient/parent/Guardian Signature
Dentist Signature
Dentist Signature
Current Date (Dentist)
DD/MM/YY
Submit
