Patient Registration Form Patient Information *All fields requiredHiddenSalutation*Mr.Mrs.Ms.Dr.First Name* Last Name* Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No HiddenPerson responsible for account* HiddenOther parental consent required* Yes No HiddenMother’s name* HiddenBusiness Tel*HiddenFather’s name* HiddenBusiness Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*HiddenAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:HiddenName* HiddenRelation* HiddenHome Phone*HiddenCell Phone*HiddenWork Phone*Contact OptionsHiddenI prefer appointment reminders by* Phone SMS (TEXT) Email HiddenAre any other members of your family patients at our practice?* Yes No Name(s) of family members attending the clinic (First and Last)*Whom may we thank for referring you?* HiddenInsurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceHiddenName of insured/subscriber* HiddenDate of Birth* MM slash DD slash YYYY HiddenPatient's relationship to subscriber* Self Spouse Child HiddenPlace of Employment* HiddenInsurance Company* HiddenPolicy/Group #* HiddenCertificate/ID #* HiddenI authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Dental HistoryDo you have any specific dental concerns? Please list:*When was your last dental appointment?* MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Name of your last Dental Clinic (for x-rays) HiddenIs there anything about the appearance of your teeth that you would like to change?*HiddenHave you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe HiddenDo you feel uncomfortable or self-conscious about the appearance of your teeth?* HiddenHave you been disappointed with the appearance of previous dental work? Do you agree to receive emails with related information and updates pertaining to your appointments? I agree to receive emails with related information and updates. CommentsThis field is for validation purposes and should be left unchanged.
