Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* Registering for a child?* Yes No Person responsible for account*Other parental consent required* Yes No Mother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home Phone*Cell Phone*Work Phone*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:Name*Relation*Home Phone*Cell Phone*Work Phone*Contact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Are 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?*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* Patient's relationship to subscriber* Self Spouse Child Place of Employment*Insurance Company*Policy/Group #*Certificate/ID #*I 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?* 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)Is there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe Do you feel uncomfortable or self-conscious about the appearance of your teeth?*Have 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.*
