New Patient Form

You will receive a 1 week call/text/email with the dollar estimate of your treatment and any forms you need to sign. You will receive a 3 day call/text/email so you can confirm your appt 2 days before to avoid a $75 short cancel fee. Lastly, because many people get sick the day before, you will also get a 1 day call/text/email so we can unschedule you and we can bring other patients for our doctors and hygienists.

Payment in full is required at time of service. We accept Visa, MasterCard, Debit/Interac, cheques or cash for your convenience. Payment plans can also be arranged if needed.

If you have dental insurance, as a courtesy, our office is happy to complete and submit your forms quickly and directly to the insurance company. However, due to the changes in many insurances we are not able to get the breakdown or frequency information for you. Pls set up your online account with your insurance. Then email or call your insurance provider and ask them to send you a full breakdown of your insurance and forward it to us so we can monitor your limits for you going forward. It can also take up for 4 months for some preauthorizations by your plan. To facilitate efficiency, we will request that you call your insurance and ask then to process your claims as soon as possible.

Thank-you for understanding. It is greatly appreciated.

New Patient
Address
Gender

If this appointment is for your child, please complete the following:

Guardian Address (If different than the patient address)
Gender

Dental Insurance

Primary Carrier

Second Carrier

Getting to know you

Health History

1. Are you feeling pain or discomfort at this time?
2. Have you had a medical examination in the last year?
3. Do you feel very anxious about having dental treatment?
4. Have you been a patient in the hospital during the past two years?
7. Are you allergic or have you reacted adversely to any of the following medications?
8. Are you aware of being allergic to any other medications or substance?
9. Circle any of the following which you have had or have at present:
10. Do you wish to speak privately to the Doctor about any medical condition?
11. When walking up stairs or taking a walk, do you ever stop because of pain in your chest?
12. Do your ankles swell during the day?
13. Have you lost or gained more than 10 pounds in the past year?
14. Do you ever wake up from sleep short of breath?
15. Are you on a special diet?
16. Has your medical doctor ever said you have a cancer or tumor?
17. Do you have a tendency to faint?
18. Do you have frequent severe headaches?
19. Have you had regular dental examination in the past year?
20. Do you have any disease, condition, or problem not listed?
further to my consultation and direct consent. I understand that responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements including insurance or otherwise, have been made.

Summary

You will receive a 1 wk call/text/email with the dollar estimate of your treatment. You will receive a 3 day call/text/email so you can confirm your appt 2 days before to avoid a $75 short cancel fee. Lastly, because many people get sick the day before, you will also get a 1 day call/text/email so we can unschedule you and we can bring other patients for our doctors and hygienists. Thank-you for understanding. It is greatly appreciated.