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New Patient Form

New Patient Form - A Dental Office

Contact Information


Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!

Your Family Physician

Emergency Contact Information

In case of emergency, We should notify:

Payment Information

Insurance Information

Please note, patient is responsible with providing us a copy of their insurance card(s).

Primary Insurance Provider

Name of Insured

Secondary Insurance Provider

Name of Insured

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Have you ever had any of the following?

Please check those that apply:

Consent for Services & Office Agreement

  • I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.
  • I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).
  • I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.
  • I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.
  • My dental insurance plan is a contract between myself and the organization providing me with the coverage.
  • It is my responsibility to ensure that the treatment I request is covered. However, will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. has NO knowledge of what is covered by my insurance plan. If I have a booklet, will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.
  • also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.
  • will always make every attempt to see emergency cases promptly.
  • will accept Visa, MasterCard, debit and cash.
  • will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent and Awareness of Use for Email and Text

  • It is my request to use email/text.
  • Email/text is not a secure system for sending/receiving information.
  • Email/text conversations will be documented in my clinical record.
  • No Email/text either sent by myself or a staff member will be forwarded to anyone else without consent of the other party.
  • Any decision by either myself or a staff member to stop the use of email/texts will be respected.

Consent for Collection, Use and Disclosure of Personal Information

  • I agree that has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.