New Patient Form

Patient Information

The personal information provided below will be protected and kept private by our office. All information will be used and disclosed responsibly
according to the Privacy Act standards set up and monitored by our office. If you have questions please ask us.

Patient Information
Insurance
Medical History
Dental History
Patient Consent

First Name *

Last Name *

Prefer to be called

Gender *

Date of Birth *

Adult or Child? *

Marital Status *

Address *

Address

Address Line 1

Address Line 2 (Optional)

City

Province

Postal Code

Email Address *

Mobile Phone # *

Home Phone #

Work Phone #

Preferred Contact Methods *

Text Mobile Phone #

Call Mobile Phone #

Call Home Phone #

Call Work Phone #

Are you available on short notice for future appointments? *

Occupation *

Employer/School *

Family Physician Name

Family Physician Phone #

In Case of Emergency, Notify: *

Relation *

Phone # *

Person Responsible For This Account: * Person Responsible For This Account:

Name (if different from self) *

Mobile Phone # *

Work Phone # *

How did you hear about us? If person, specify name. *

Patient Information

Emergency! If you are in need of urgent dental care we will try our best to see you immediately.

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