New Patient Registration & Medical History

Registering in advance saves you time at your appointment

Please fill-out our Patient Registration Form online. If you choose to download and print the form, please make sure you bring it on your first visit to our office once it is completed. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

 

REGISTRATION / MEDICAL HISTORY QUESTIONNAIRE

Patient Registration (new)

PERSONAL INFORMATION

First Name
Middle Initial(s)
Last Name
STREET
APT #
CITY
PROVINCE
POSTAL CODE

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

INSURANCE INFORMATION

(if applicable)
First / Last Name
(MM/DD/YYYY)

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
I AUTHORIZE THE RELEASE OF ALL PERTINENT INFORMATION RELATIVE TO MY DENTAL HISTORY (INCLUDING X-RAYS) TO ANY DENTIST OR PHYSICIAN INVOLVED IN MY TREATMENT AND TO MY DENTAL INSURANCE COMPANY, WHERE APPLICABLE.
(PRINT NAME)
Sending

 

Download Our Patient Registration Form

Technical Note: If you choose to download and print the form, you need Adobe Acrobat Reader to view our form. Please download the free Acrobat Reader from Adobe’s web site if it is not already installed on your system.

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