New Patient Medical History Form

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Privacy Policy and GDPR Compliance

I read and accept Privacy Policy and GDPR Compliance*

In providing your dental care and treatment, we will ask for information about you and your health. The dental clinic is required, in accordance with the Law on the Consolidation and the Protection of the Rights of Patients of 2004, Law No. 1(I)/2005, to keep patient medical records and maintain them updated according to the Law on the Processing of Personal Data (Protection of Individuals) Law of 2001 and 2003. The storing and processing of this data, the persons who have access thereto, along with the time period for which they shall be stored is governed by the Law on the Processing of Personal Data (Protection of Individuals) Law of 2001 and 2003, as well as by the European Regulation (EU) 2016/6/679 on the protection of natural persons with regard to the processing of the personal data.

This data is kept in print, electronic form or both. This information is part of your medical record and shall be kept in case you visit the dental clinic in the future. The data retention period shall not exceed 15 years after the Patient's death or after the last processing of data in the file. This privacy notice describes the type of personal information we hold, why we hold it and what we do with it.

Information that we collect

We may collect the following information about you:

Personal details such as your name, date of birth, insurance number, ID number, address, telephone and email

Information about your dental and general health, including:

Clinical records made by dentists or other dental professionals involved with your care and treatment

Medical and dental history

Treatment plans and consent

Notes of conversations with you about your care

X-rays, clinical photographs, digital scans of your mouth and teeth, and study models

Dates of your appointments

Correspondence with other health professionals or institutions

Details of the fees we have charged, the amounts you have paid and payment details

The practice owner is responsible for keeping this information secure and ensuring that the practice complies with data protection requirements to collect, use, store and dispose of your information responsibly.

How we use your information

To provide you with the dental care and treatment that you need, we require up-to-date and accurate information about you.

We will seek your preference for how we contact you about your dental care. Our usual methods are sms, telephone or email.

Sharing information

Those at the practice who have access to your information include dentists and other dental professionals involved with your care and treatment, and the reception staff responsible for the management and administration of the practice. Your information is normally used only by the clinical team (personnel and partners) of FLOSS Dental Clinic but there are instances where we need to share it – for example, with:

Your personal doctor

The hospital or community dental services, labs, technicians or other health professionals caring for you.

Accounts and billing for GESY payment authorities, relevant insurance agencies or private medical or dental insurance of which you are a member.

Anonymously through online platforms, pamphlets or journal publications for educational, training and research purposes.

In certain circumstances or if required by law, we may need to disclose your information to a third party not connected with your health care, including law enforcement, government agencies or accountants.

We will only disclose information on a need-to-know basis and will limit any information shared to a minimum.

Keeping your information safe

We store your personal information securely in our practice. Your information cannot be accessed by those who do not work at the practice; only those working at the practice have access to your information. They understand their legal responsibility to maintain confidentiality and follow practice procedures to ensure this.

We take precautions to ensure security of the practice premises, network safety, the practice filing systems and computers. We use specialized software to record and use your personal information safely and effectively and we back-up information securely and routinely.

Access to your information and other rights

You have a right to access the information that we hold about you and to receive a copy. You should submit your request to the practice in writing. We do not usually charge you for copies of your information; if we pass on a charge, we will explain the reasons.

You can also request us to correct any information that you believe is inaccurate or incomplete, erase certain information (although for legal reasons, we may be unable to erase certain information such as dental treatments performed) or to stop using your information (for example, sending you sms reminders). You may also request that we supply your information electronically to another dentist.

If you do not agree

If you have any concerns about how we use your information, you should discuss the matter with your dentist. If you object to the way that we collect and use your information, we may not be able to continue to provide your dental care. For any further concerns, the Office of the Commissioner for Personal Data Protection can be advised (commissioner@dataprotection.gov.cy).

GDPR and Your Data

If you would like us to delete your personal information, or you would like to receive a copy of the information we hold about you, please email us at: info@andreakapsou.com.

I agree with the Privacy Policy and GDPR Compliance of Floss Dental Clinic.

Signature*

New Patient Medical History Form

Personal Information

Welcome to our clinic.

Thank you for choosing us for your dental care!

The following personal information and medical history are completely confidential and are not shared with any third parties other than the dental team.

Name*

Surname First Name

Date of birth*

MM slash DD slash YYYY

Occupation*

ID No*

ID Type*

Address*

Street Address City Postal Code

Phone:

Mobile:*

Email:*

Emergency contact:*

Mobile:*

How did you learn about FLOSS Dental Clinic?

Friends/Relatives or Other:

Please specify

Would you like to be treated by a particular dentist?

Yes

Prefered Dentist Name:

Dental History

What is the reason for today’s visit?*

Have you recently taken a panoramic radiograph (within 4 years)?*

Yes

Do you visit the dentist regularly?

Yes

When was your last dental visit?*

Do you brush your teeth twice a day?

Yes

Do you use dental floss or interdental brushes?

Yes

Have you noticed any of the following, if yes please choose whichever apply?

Sharp, throbbing or dull pain on a particular tooth

Dental Temperature Sensitivity

Food impaction between teeth

Bleeding or inflamed gums

Bad breath (halitosis)

Clenching or grinding of teeth

Dental Infection or Abscess/Swelling

Pain, clicking or crepitus in TMJ

Have you ever undergone periodontal therapy?

Do you wear a nightguard?

Are you satisfied with your smile?*

Yes

If not, what would you like to improve?

Tooth shape or size

Whitening

Gums

Alignment

Would you like to be informed about relevant cosmetic options?*

Medical History

Name of Personal Doctor:*

Telephone:*

Have you been hospitalized for any surgical procedure or serious illness in the past 5 years?*

Yes

If yes please explain:

What is your resting Blood Pressure?*

What is your resting Blood Pressure? (Normal, High, Low, I don't know.

Do you smoke cigarettes?*

Yes

If yes, how many cigarettes do you smoke daily?

Do you take any blood thinners or anticoagulants?*

Yes

(eg. Aspirin, Xarelto, Plavix)

Do you take any bisphosphonates or similar drugs (pills or injectable) for osteoporosis/osteopenia?*

Yes

Please list any medications you take on a daily basis (including vitamins or contraceptives) and for what purpose?*

Do you or have you ever had any of the following?

Open Heart Surgery/Stent/By-pass:

Diabetes Mellitus:

Mitral Valve prolapse or regurgitation:

Hepatitis Α / Β / C:

Prosthetic valve or pacemaker:

Stomach ulcer or gastritis:

Antibiotic Prophylaxis for Endocarditis:

Kidney Failure or Transplant:

Hemophilia/ Anemia/ G6PD allergy:

Hormonal Imbalance (eg. Thyroid):

Hypertension/ Hypotension /Cholesterol:

Cancer (Radiotherapy, Chemotherapy):

Asthma /COPD:

Stroke/ Epileptic Seizure:

Tuberculosis:

HIV / AIDS:

Coronavirus:

Other Autoimmune Disorder:

Any other medical condition?

Are you allergic or have you ever had any allergic reaction to any of the following?

Local Anesthesia?

Penicillin or any other antibiotic?

Anti-inflammatories/painkillers/aspirin?

Metal allergy?

Latex?

Any other known allergies:

If female, are you pregnant or breastfeeding?*

Yes

Do you faint easily?*

Yes

Would you like to receive semi-annual or annual recall reminders via sms?*

Yes

How often would you like to receive recall reminders?

Yearly

Semi-yearly (recommended)

Consent*

I understand that at FLOSS Dental Clinic, all cases are photographed for documentation purposes and to achieve the best aesthetic result. I consent to the use and publication of anonymous teeth/smile photos for educational, research, statistical and scientific purposes.

- I have read and understood the “FLOSS Dental Clinic Privacy Policy and GDPR Compliance". I consent to the collection and processing of my personal data, including the sensitive data above, for the purposes of effectively conducting the Clinic's operations.

I have read, understood and accept all of the above and answered the questions carefully. I confirm that this information is true and correct to the best of my knowledge. I will notify you in the future of any changes to the above information.

Signature*