Ajax: 905-239-3478
Bowmanville: 905-419-5232

New Patient form

New Patient Intake Form
Patient Name
Date of Birth*
Address *
Phone*
Email
Do you have dental insurance?
Insurance company name
Certificate / ID Number
Group / Policy number
Are you a dependant? Yes / No
Name of insurer
Insurer date of birth
Relationship
Insurance company name
Certificate / ID Number
Group / Policy number
Are you a dependant? Yes / No
Name of insurer
Insurer date of birth
Relationship
How did you hear about our clinic?*
MEDICAL HISTORY - Do you have a family physician?
Name
Phone
Do you have a dentist?
Name
Phone
Have you ever had any head, facial, jaw or neck trauma?
Do any of the following conditions apply to you?
.
.
Additional condition details
Do you smoke?*
Are you allergic to the following?
Please specify allergy
Have you ever had or are going through radiation or chemotherapy?
When did you last go through radiation or chemotherapy?
Do you have hearing or memory issues where you may need extra assistance?
Do you have any of the following serious illnesses?
If you have a serious illness that is not listed, please list
Is there anything else the denturists should know about your health?
CONSENT
SMS Notifications
Name
Date