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?

    Are you a new or current patient?

    Patient Contact Information

    Patient Type


    Name of Patient


    Best way to contact you:

    Insurance Information

    Primary Insurance Company

    Insurance Policy Holder

    Secondary Insurance Company Information

    Insurance Policy Holder

    Financial Information

    Person responsible for account

    Preferred Method of Payment

    Dental History

    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

    Do you have, or have you had any of the following?

    If you could change your smile, you would

    How important is your dental health to you?

    On a scale of 1 to 10, with 10 being the highest rating

    Where would you rate your current dental health?

    On a scale of 1 to 10, with 10 being the highest rating

    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?

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

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

    Do you have any allergies?

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

    Do you have or have you ever had asthma?

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

    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?

    Do you have a prosthetic or artificial joint?

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

    Have you ever been hospitalized for any illnesses or operations?

    Do you have or have you ever had any of the following? Please check all that apply.

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

    Do you smoke or use other nicotine products?*

    Are you pregnant?

    Are you breastfeeding

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

    General Release

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

    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.