Dental Intake Form

Please correct the errors described below.

Welcome to Cataraqui Woods Dentistry!

If you are an existing patient with us already, please visit our Request an Appointment form.

Please note that this form cannot be submitted if fields marked with an asterisk (*) are left blank.

Patient's Personal and Contact Information

Emergency Contact Person(s)

Insurance Information

Please remember to bring your insurance card/information with you during your first appointment.

You be required to pay the full bill out of pocket without proof of insurance documentation.

If you do not have insurance, type "OOP" for Out of Pocket

Medical History Questionnaire

For example, a heart condition or a recent joint replacement.
If there is nothing else, please type "Nothing else."
If there is nothing else, please type "Nothing else."

Dental History Questionnaire

For example, one pack of cigarettes per day.
If there is nothing else, please type "Nothing else."

Assignment of Benefits Disclaimer

As your dental provider, we try our best to learn all that we can about your dental benefits. However, there are numerous service providers and over 30,000 dental benefit plans in Ontario. We cannot always gain complete access to the full details of your benefits package. Your particular plan may not cover the full cost of your dental visit. We cannot guarantee that your insurance provider will fully cover your treatment.

Predeterminations Disclaimer

Due to the Privacy Act, your insurance company will not provide us with the results of any of your dental predeterminations. You are responsible for contacting your insurance company to find out the results. We will require you to provide us a copy of your estimate response prior to your appointment to allow us to ask your insurance provider to pay us directly and assume your co-payment. Without this estimate, you will be responsible for the full payment at the time of treatment.

Thanks for joining the Cataraqui Woods Dentistry family!

If you've sent this new patient form during our business hours, we'll start working on it right away.

If you've sent this outside of our business hours, we'll receive at 8:00am, Monday to Friday.


Cataraqui Woods Dentistry

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