New Patient Form

We understand that your time is valuable and in order to streamline your first visit, simply complete at your convenience, prior to your appointment.

How did you hear about us?

Give some Details:

Are you a new or current patient?

New Patient

Current Patient

Patient Contact Information

Patient Type

AdultChildAdult Under Guardianship

Name of Guardian

Gender

Male

Female

Other

Name of Patient

First Name

Last Mame

Date of Birth

Address

Address Line 1

City

Select Province

Postal Code

Select Country

Primary Phone Number

Home Phone Number

Work Phone Number

Best way to contact you:

Primary

Home

Work

Family Physician

Specialist Name

Emergency Contact

Emergency Contact Phone Number

Insurance Information

Primary Insurance Company

Insurance Policy Holder

SelfSpouseParent/GuardianNone of the Above

Insurance Company Name

Name of Insurance Policy Holder

Holder Date of Birth

Group Policy/Plan Number

ID/Certificate Number

Secondary Insurance Company Information

Insurance Policy Holder

SelfSpouseParent/GuardianOther

Please Describe:

Insurance Company Name

Name of Insurance Policy Holder

Policy Holder Date of Birth

Group Policy/Plan Number

ID/Certificate Number

Financial Information

Person responsible for account

SelfSpouseParent/GuardianOther

Please Describe:

Preferred Method of Payment

Interact

Visa

Cash

Mastercard

Dental History

Date of your last dental exam

Date of your last dental cleaning

Date of your last dental x-rays

Please check any of the following problems that may apply to you.

Sensitivity (hot, cold and/or sweet)Tooth pain or discomfort while chewingHeadaches, earaches or neck painJaw joint pain (clicking/cracking)Grinding or clenching teethBleeding, swollen or irritated gumsLoose, chipped or shifting teethBad breath or bad taste in your mouthNone of the above

If you could change your smile, you would

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.

Are you currently being treated for any medical condition or have you been treated within the past year?

YesNo

Please Describe:

Has there been any change in your general health in the past year?

YesNo

Please Describe:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

YesNo

Please Describe:

Do you have any allergies?

YesNo

Please Describe:

Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNo

Please Describe:

Do you have or have you ever had asthma?

YesNo

Please Describe:

Do you have or have you ever had any heart or blood pressure problems?

YesNo

Please Describe:

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

YesNo

Please Describe:

Do you have a prosthetic or artificial joint?

YesNo

Please Describe:

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?>

YesNo

Please Describe:

Have you ever been hospitalized for any illnesses or operations?

YesNo

Please Describe:

Are there any conditions or diseases not listed above that you have or have had?

YesNo

Please Describe:

Do you smoke or use other nicotine products?*

YesNo

Please Describe:

Are you pregnant?

YesNo

Expected Due Date

Are you breastfeeding

YesNo

Do you have a disability or are a person with visual impairment

YesNo

Please Describe:

General Release

I agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.

I agree

I do not agree

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.

We are dedicated to giving each of our patients the healthy smile they deserve! Your teeth play an important part in your daily life.

380 King Street North Waterloo, ON N2J 2Z3

(519) 747-9797

[email protected]

Our Services

We're Available

Monday :

10:00am – 7:00pm

Tuesday :

10:00am – 7:00pm

Wednesday :

10:00am – 7:00pm

Thursday :

10:00am – 7:00pm

Friday :

10:00am – 7:00pm

Saturday

10:00am – 7:00pm

Sunday:

8:00am – 3:00pm

New Patient Form

Patient Contact Information

Insurance Information

Primary Insurance Company

Secondary Insurance Company Information

Financial Information

Medical History

General Release

Our Services

We're Available

Location