Patient Registration Form

Your cooperation in completing this questionnaire is essential to providing with the highest standard of dental care. Please answer as accurately as you can. If you have any questions or doubts, please ask the treating dentist or our receptionist, who is available to assist you with the completion of this form. All information is strictly confidential and will remain with the office.

Full Name

Address

Work Phone No.

Home Phone No.

Cell Phone No.

Date of Birth

Email address

Family Physician

Previous Dentist

Who me we thank for referring you?

Nearest relative not leaving with you

Address

Telephone No.

Relationship

INSURANCE INFORMATION

Name of Policy Holder

Date of Birth

OHIP No. (Optional)

Name of Employer

Group Policy No.

Certified ID No.

Insurance Company

Fee Guide

Insurance Phone No.

Insurance Year end

Maximum Coverage

Employer

Insurance Company

CONFIDENTIAL MEDICAL HISTORY

1. Date of last physical examination

4. Have you recently or are you presently taking any prescription or non-prescription drugs? (include dosage or please provide a copy of a receipt from pharmacist)

5. Are you taking Anti-coagulants? If yes, what is your most recent INR.

If yes, Please specify

How long

A) If yes, List # of Cigarettes

If yes why?

Please specify

If yes, for how long?

CONFIDENTIAL DENTAL HISTORY

Please specify

2. When was your last dental visit?

When was your last dental cleaning?

If yes, Please specify

We will be happy to help you complete your insurance forms with the information you have provided us. Payment for dental treatment is required when services are rendered unless an alternative financial agreement has been arranged.

This is to certify that I, the undersigned have provided an accurate and complete personal and medical/dental history and consent to the performing of the dental procedures agreed to be necessary.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient (parent's) Signature

Date

Your information will be encrypted.

Patient Registration Form

INSURANCE INFORMATION

CONFIDENTIAL MEDICAL HISTORY

CONFIDENTIAL DENTAL HISTORY

Tanglewood Dental Office