Request an Appointment

The information in this form is required to enable us to provide you with the best possible dental care. Cataraqui Woods Dentistry complies with all relevant privacy laws and regulations. Any information that you communicate to Cataraqui Woods Dentistry is safe, secured, and encrypted.

Want to join the Cataraqui Woods Dentistry family? Please fill out our "New Patient Intake" form.

This form is for existing patients only..

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

Personal and Contact Information

Given Name

Surname

Preferred name

Date of Birth

Street Name and Number

City Name

Province

Postal Code

Primary Contact Number

Please limit to 10 numbers.

Email address

Above DOB indicates a minor. Tick this box if this is accurate. If inaccurate, please correct DOB.

Above DOB indicates a future DOB. Please correct this field. If you are unable to correct this field, tick this box and let us know.

Which days are you available?

Monday

Tuesday

Wednesday

Thursday

Friday

I am available Monday through Friday.

Which times slots are you available?

8:00 AM to 12:00 PM

12:00 PM to 4:00 PM

4:00 PM to 8:00 PM (Tuesdays Only)

I am available during all of these times.

Please detail any exceptions. We'll try to work around them for you.

New Appointment Questionnaire

1. For the information you just entered, which of the following applies? We will update your file.

None of the above information has changed since my last appointment

My address has changed since my last appointment

My email address has changed since my last appointment

My primary contact number has changed since my last appointment

My availability has changed since my last appointment

My name/preferred name has changed since my last appointment

Select all that apply to the person responsible for your account. We'll make sure it's up to date. This section should only appear if you are a minor. If you are not a minor, please correct your DOB.

My parent/guardian has the same address, email, and primary contact number

My parent/guardian has a different address, email, and primary contact number

My parent/guardian has a different address

My parent/guardian has a different email

My parent/guardian has a different primary contact number

Street Name

City Name

Province Name

Postal Code

Primary Contact Number

Please limit to 10 numbers.

Email address ‎

Was there something else you had in mind?

3. Are you experiencing any of these?

Not experiencing any problems

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding gums

Tooth pain or discomfort while chewing

Jaw joint pain

Sensitivity (hot, cold, and/or sweet)

Broken teeth or fillings

Experiencing something not listed

If you answered "experiencing something not listed," please specify.

5. Thinking about your insurance, does any of the following apply? If there have been any changes to your insurance, please assist us by bringing in all new documentation.

No insurance information has changed / I did not have insurance at my last appointment

I've changed my insurance policy holder since my last appointment

I have the same policy holder, but my plan has changed since my last appointment

I had insurance coverage at my last appointment, but no longer have insurance coverage

Please list your new policy holder, policy/plan number, and/or certificate/identification number.

7. Is there anything else regarding your dental treatment that we should be aware of?

8. Do you have any other feedback, suggestions, or questions?

Thanks for your inquiry! If you've sent this 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.

Sincerely,

Cataraqui Woods Dentistry

Your information will be encrypted.