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?
To help us with a proper diagnosis and appropriate treatment plan, have your bed partner, if applicable and available, fill out this questionnaire regarding YOUR sleep habits. This information is vitally important for Patrick Strong to best evaluate your current condition.
To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to your primary physician and family dentist.
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.
REASON FOR VISITING:
Snoring & ApneaDenturesOther
Please note that the Strong Denture & Snoring Clinic, located at 3200 Deziel Dr. Suite 118, near the South West corner of EC Row and Central Ave, is still open to assist you.
We are taking extra precautions to help ensure a safe environment for all patients and our team:
We are performing digital scans of the patient’s teeth instead of taking impressions. Digital scanning is a more comfortable experience for patients, particularly those with dental anxiety. Digital scanning is a safe, non-invasive, and extremely accurate way of taking impressions that does not irritate the gag reflex. Whole mouth scans can be completed in under 10 minutes.
To book an appointment or schedule a no-fee, no-obligation phone consultation today, please call 519-979-0070 or 1-877-891-8634 and leave your name, phone number, and email address along with a detailed message, and I will contact you at the earliest opportunity. You can also send a detailed message to firstname.lastname@example.org.
Thank you for your understanding. Stay safe and I look forward to seeing all of my current and future patients soon.
-Patrick J Strong DD, FCAD
Strong Denture & Snoring Clinics
Click here to view our locations in Windsor, The GTA and Cobourg