Welcome To Our Office

Name

PrefixFirst NameMiddle NameLast Name

Preferred Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Number Location

Other

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Number Location

Other

E-Mail

example@example.com

Personal Health Number (PHN)

Numeric PHN

Emergency Contact

Emergency Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

2nd Emergency Contact

2nd Emergency Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Date of Birth

Date

Person responsible for account (and relation to patient if applicable):

Do you have dental insurance coverage?

Primary Dental Plan

Rows	Dental Insurance Information
Insurance Company
Employer
Name of Insured
Insured Date of Birth
ID / Certificate #
Group / Policy / Contract #

Secondary Dental Plan

Rows	Dental Insurance Information
Insurance Company
Employer
Name of Insured
Insured Date of Birth
ID / Certificate #
Group / Policy / Contract #

Note: Please be aware of any limitations to your plan since responsibility for your account belongs to you. Our staff will gladly handle your insurance details.

How did you hear about our office?

What are your reasons for visiting our dental clinic?

How long has it been since your last dental check-up?

Do you have concerns with any of the following (please check)?

Other

Do you experience any of the following problems (please check)?

Are you currently being treated by a physiotherapist or chiropractor for any neck, shoulder or spinal problems?

Have you ever had a traumatic experience in a dental office?

Does any type of dental treatment make you feel nervous, anxious or nauseous?

Patient Consent (please check):

I, the undersigned hereby consent to take x-rays, photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis. I consent to the dental treatment agreed upon and also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for dental services rendered in this office is expected at the end of each appointment unless other financial arrangements have been made. Furthermore I authorize release of information from my dental plan administrator and consent to electronic submission of my dental claims.

Name of parent / guardian signee (if applicable)

Signature

Date