Simcoe Family Dentistry New Patient Registration

PATIENT REGISTRATION
Personal Information
First Name*
Last Name*
Initial
Address:*

Address

Street Address Line 2

City/ProvState / Province

Postal Code
City/Province

Street Address Line 2

City/ProvState / Province

Postal Code
Postal Code

Street Address Line 2

City/ProvState / Province

Postal Code
Day of Birth
Month of Birth
Year of Birth
Age
Email
example@example.com
Home Phone
Work Phone
Cell Phone
Preferred Contact Method:*

Home PhoneWork PhoneCell PhoneEmailText
By providing an email and/or cell phone number for text messages, I authorize Simcoe Family Dentistry to correspond with me in that manner. I understand that email and text message communications are not secure forms of communication and that confidentiality of any email or text message cannot be ensured. I understand that this authority is to remain in effect until Simcoe Family Dentistry has received written notification from me of its change or termination.
Emergency Contact*
Name
Relationship
Phone#*
Last time at a dentist and for what reason?
How many times a day do you brush?
How many times a day do you floss?
Do you have any dental concerns and if so, what are they?
Are you happy with your oral health?
Are you happy with your smile?
What would you change?
How did you hear about us?

Internet SearchGoogle AdFacebookPatient NameReferred from Another OfficeOther
Patient Name?
Name of Patient
Referred from another office
Name of Office
Other
Please Specify
Financial/Insurance Information:

At Simcoe Family Dentistry, payment is due on the day treatment is provided. If you have dental insurance, we will gladly submit the claim electronically on your behalf to avoid re-imbursement delays. We accept Visa, MasterCard, Debit and Cash. Our fees are generally based on the ODA Fee Guide for the current year. If you have any questions regarding our fees, please inquire. It is not possible for Simcoe Family Dentistry to know the extent of your insurance benefits, restrictions and limitations. When we call on your insurance company and verify benefits it is not a guarantee of payment by the insurance company.
Initial*

Clear
I have read and understood the financial/insurance information
We require 48 hours notice to cancel or reschedule an appointment. If you need to change or cancel an appointment, please call during normal business hours. If an appointment is cancelled with less notice or you do not show for your appointment, we reserve the right to charge a cancellation fee.
Initial*

Clear
I have read and understood the cancellation policy.
Who is responsible for your account?*

SelfSpouseParentOther
Other
Please Specify
PRIMARY DENTAL INSURANCE
Name of Insured
Date of Birth

MonthDayYear
Insurance Co.
Policy#
ID#
Employer
SECONDARY DENTAL INSURANCE
Name of Insured
Date of Birth

MonthDayYear
Insurance Co.
Policy#
ID#
Employer
I, the undersigned, state that I have completed all information forms accurately, without knowingly omitting any information. On the basis of confidentiality, I hereby consent to the release and transfer of any patient information and dental records within my file for dental insurance purposes or interpractitioner communication. I agree that Simcoe Family Dentistry have obtained informed consent from me with respect to the collection, use, and disclosure of my personal health information. If asked, I will be provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004. I also authorize release, to my benefits plan administrator and CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described by Simcoe Family Dentistry.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION

Personal Information