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Online Form

Welcome Form

Our wish is to serve you better. This is why we ask that you complete this form to help expedite any future appointments and so that we get to know you better. All information provided to our office is confidential and protected by P.I.P.E.D.A & P.H.I.P.A (Government mandated privacy policies).

Personal Information

Birthday

Gender



How should we contact you?



Required for some prescriptions. Enter only License OR Healthcard.

Emergency Contact Info

About Your Work

Insurance Information

Medical History

Dental History

I understand the above information is necessary to provide me with dental care in a safe manner. I have answered all the questions to the best of my knowledge. Should further information is needed; the office has my permission to ask the respective health care provider to release such information. I will notify the office and dentist of any change in my health or medication. I understand that the office will do their best to work with my insurance company; however some insurance companies do not work with the dental offices and prefer to work directly with the patients. I understand that for any overdue fees a charge of 2% will apply. I understand that I am fully responsible for all the bills incurred in this office if the insurance does not honour the claims. I give authorization to the dentist to perform any treatment needed and to provide local anesthetic as is needed.