- My Forms at Home

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Phone #

Type

Ext

Phone #

Type

Ext

Phone #

Type

Ext

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health history have an important relationship with your dental treatment. Please answer the following questions:

Please go over the following section and indicate which of the following you have or have had. If you need to add any further information, please provide.

DENTAL INFORMATION

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire, and there may be additional questions concerning your health.

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also give consent to contact my physicial, dental insurance company and referring specialists if necessary, as this information may be required for my dental care.

Consent for Treatment