Patient Information Form - The Dentistry Place

Patient Information

Patient Name*

Prefix First Middle Last

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City Province Postal Code

How would you like us to call you? (Check all that apply.)*

Mobile Phone

Home Phone

Work Phone

Mobile Phone

Home Phone

Work Phone

Date of Birth (dd/mm/yyyy)*

Sex*

Male

Female

Other

Sex (Other)

Marital Status*

Occupation

Employer

Emergency Contact Name*

Emergency Contact Phone Number*

Relationship*

What is your relation to your emergency contact?

Do you have a previous dentist that you wish to transfer patient records from?*

Yes

No

How did you hear about us or who can we thank for referring you?

Insurance Information

Do you have dental insurance coverage?*

Yes

No

Who is the primary policy holder?*

Self (Patient)

Spouse

Parent/Guardian

Policy Holder Name*

Policy Holder Date of Birth*

Insurance Company Name*

Insurance Policy Number*

Identification Number*

Do you also have secondary insurance coverage?*

Yes

No

Secondary Policy Holder Name*

Secondary Policy Holder Date of Birth*

Secondary Insurance Company Name*

Secondary Insurance Policy Number*

Secondary Identification Number*

Office Policy

Payments: Payment for service is expected at the end of each visit. Certain circumstances require special consideration. Please discuss these with your dentist.
Appointments: In order to treat you effectively, we will reserve an appointment time solely for you. We require your co-operation in keeping these appointments. If you cannot keep your appointment time, we require 48 hours notice. Otherwise a fee will be assessed.

Consent for Treatment

This is to certify that I, the undersigned, have read the forgoing and consent to the performing of the dental procedures agreed to be necessary or advisable. I will assume responsibility for fees associated with those procedures.

Do you agree to these policies and consent to treatment?*

Yes

Patient/Parent/Guardian Signature:*

New Patient Information Form

Patient Health Record