Airdrie Online Registration Form

Online Registration Form

Please complete each section of the form below.
Patient Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail
Date of Birth

MonthDayYear
Age
Employer
Health Care Number
Province
Referring Dentist or Doctor
Purpose of Visit
Family Dentist
Family Physician

Person Financially Responsible
Full Name

First NameLast Name
Relationship to Patient
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail
example@example.com

Dental Insurance Information
Name of Insurance Company
Policy / Group #
Certificate / ID #
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Address if Different from Patient

Street Address

Street Address Line 2

CityProvince

Postal Code
Subscriber's Employer
Relationship to Patient
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail
example@example.com

Secondary Dental Insurance Information
Name of Insurance Company
Certificate / ID #
Policy / Group #
Subscriber's Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Subscriber's Employer
Relationship to Patient
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail
example@example.com
Government Coverage

Please present your coverage card if you are eligible with the following plans
Worker's Compensation Claim #
SIN #
Social Assistance / Alberta Works & Children's Health benefit / AISH? ID #
NIHB / First Nation / Inuit ? ID #
Band Name
Should be Empty: