New Patient Form

Full Name

Preferred Name

Date of Birth

Gender
MaleFemaleOther
Address

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

E-mail Address

Emergency Contact or Responsible Party if under the age of 18

Name

Phone

Friend Referral (Please provide name)GoogleSocial Media

Reason for current appointment
[texta rea textarea-396 "Reason for current appointment:"]

Do you have any oral habits such as clenching, grinding or thumb sucking?YesNo

YesNo

Do you have any jaw joint problems?
YesNoI’m not sure

Do you have bleeding gums?
YesNo

Do you suffer from bad breath or halitosis?
YesNo

How would you assess your general health?
GoodFairPoor

Have you been hospitalized in the last 3 years?YesNo

[textarea List all the medications you take (Please include prescription and over the counter) "Reason for current appointment:"]

Your email

Subject

Your message (optional)

New Patient Form

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Cancellation Policy:

It is our optimal goal to provide you and your family with the highest quality of dental care, while maintaining a frilly and lacing environment. To keep me standard of care to a level which best serves your dental needs, ask that you observe the following:

Our clinic requires a minimum of 2 business days' notice if an appointment must be canceled or rescheduled. A short notice cancellation by one patient means another patient who is suffering or is in pain has missed an opportunity to be seen by the doctor, We feel very strongly about it and to deter people from such practice, we assess a fee of $75.00 to any short notice cancellation: Exception homer will be code for illness or personal tragedy.

In the event that a patient does not show up to their scheduled appointment on a second occasion, we may ask the patient to find a different dental office to serve them at which point our administrative staff will be happy to forward the patient's records to the new dental office

Please note: Insurance companies do not cover the cost of missed or cancelled appointments; therefore, payment is made the patient’s responsibility prior to rescheduling.

Patient Acknowledgements:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health or other pertinent information, I will inform the doctors at my next appointment without fail.

By initialing the insurance information, I am acknowledging that I have read and understood the statement pertaining to my insurance status

I have read and understood the cancellation policy

Treatment Policy:

I authorize the doctor to take X-rays, study models, photographs, or other diagnostic materials deemed appropriate by the doctor to make a thorough diagnosis of my dental health condition. Upon my verbal agreement following discussion of recommended treatment, I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the services required for my dental health. I further authorize and consent that the doctor chooses and employs such assistance as deemed fit.

Signature
Date
(Parent or Guardian if the patient is under 18)

You and your family might be eligible for the new government dental plan | visit page or call us or fill the form to find out.

New Patient Form

New Patient Form

New Patient Form

Cancellation Policy:

Patient Acknowledgements:

Treatment Policy:

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