Dental Registration and History

Office Location *

Are You an Existing Patient Yes

1. Patient Information

Patient name *

Mailing Address *

City

Province

Postal Code

Date

Sex

Age

Birthday *

Does anyone in the immediate family attend this office? The office can link family members together. Yes

If so, who?

Hosp # *

First Canadian Health

Occupation (children not required)

Employer Name

Employer Phone

Spouse's Name

Spouse's Birthday

Spouse's Employer

Spouse's Occupation

2. Phone Numbers

Home *

Cell

Spouse's Work

What is the best method to contact you to remind you of your dental appointment?

In Case of emergency, contact

Name

Relationship

Daytime Phone

Other Phone

3. Dental Insurance

First Insurance - Relationship to Patient

Insurance Co.

Insurance ID# or Certificate #

Policy or Group #

Second Insurance - Relationship to Patient

Insurance Co.

Insurance ID# or Certificate #

Policy or Group #

6. Authorization and Release

I have read and answered the above questions to the best of my knowledge. I authorize the doctor to release all information neccessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.

Date

1. Patient Information

2. Phone Numbers

In Case of emergency, contact

3. Dental Insurance

4. Dental History

Check the box if you've had any of the following

5. Health History

Check the box if you've had any of the following

Allergies

6. Authorization and Release