Patient Registration Form Patient Information *All fields requiredThis field is hidden when viewing the formSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No This field is hidden when viewing the formPerson responsible for account*This field is hidden when viewing the formOther parental consent required* Yes No This field is hidden when viewing the formMother’s name*This field is hidden when viewing the formBusiness Tel*This field is hidden when viewing the formFather’s name*This field is hidden when viewing the formBusiness Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*This field is hidden when viewing the formAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:This field is hidden when viewing the formName*This field is hidden when viewing the formRelation*This field is hidden when viewing the formHome Phone*This field is hidden when viewing the formCell Phone*This field is hidden when viewing the formWork Phone*Contact OptionsThis field is hidden when viewing the formI prefer appointment reminders by* Phone SMS (TEXT) Email This field is hidden when viewing the formAre 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?*This field is hidden when viewing the formInsurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceThis field is hidden when viewing the formName of insured/subscriber*This field is hidden when viewing the formDate of Birth* MM slash DD slash YYYY This field is hidden when viewing the formPatient's relationship to subscriber* Self Spouse Child This field is hidden when viewing the formPlace of Employment*This field is hidden when viewing the formInsurance Company*This field is hidden when viewing the formPolicy/Group #*This field is hidden when viewing the formCertificate/ID #*This field is hidden when viewing the formI 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)This field is hidden when viewing the formIs there anything about the appearance of your teeth that you would like to change?*This field is hidden when viewing the formHave you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe This field is hidden when viewing the formDo you feel uncomfortable or self-conscious about the appearance of your teeth?*This field is hidden when viewing the formHave 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?Consent receive emails I agree to receive emails with related information and updates. Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*CommentsThis field is for validation purposes and should be left unchanged.
