Patient Information

If you would prefer to print the forms instead please use the following links:

1 – Patient Information
2 – Epworth & CPAP Questionaire
3 – Bed Partner Survey
4 – Patient Medical Information



How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
If you have not worn a CPAP device, SKIP THIS SECTION


We will gladly provide you with insurance pre-determinations, claims and any necessary information for each visit. Depending on the insurance company we may, or may not be permitted to take assignment of benefits. Please let us know if you have any questions.

The office of Patrick Strong DD will collect, use & disclose information about you in the following manner.

1.To identify & ensure high quality service is provided to our clients on a continuous basis.

2.To deliver safe patient health care.

3.To assess your oral health needs & to advise you of treatment options.

4.To communicate with your health care providers including your doctor, dentist, dental hygienist or outside laboratory services if necessary.

5.To contact you & maintain communication with you to ensure that your denture service & treatment are met on an ongoing basis.

6.To provide treatment care information or services related to your general & specific oral health needs.

7.To contact you, book or to confirm appointments.

8.To contact you to efficiently follow up on treatment, quality of care, & payment.

9.To complete & submit dental and/or medical claims for third party adjudication & payment.

10.To comply with legal or regulatory requirements under the Regulated Health Professions Act, The Health Professions Procedural Code, The Denturism Act, & associated regulations.

11.To prepare materials for The Privacy Commissioner and/or our liability insurance carrier as required.

12.To invoice for goods & services, to process credit/debit card payments or to collect unpaid accounts.

13.To allow this office to comply with all regulatory requirements & with the laws of Ontario & Canada.

By signing this consent form, YOU AGREEthat you have given your informed consent to the collection, use &/or disclosure of your personal information for the purposes that are listed your information may be accessed by the College of Denturists of Ontario or other regulatory authorities acting under statue, or in defense of a legal issue. We will seek your approval, in advance, if a new purpose arises for the use &/or disclosure of your personal information unless the use or disclosure is required by law.