New Patient Form

First Name

Last Name

Preferred Name

Street Address

City

Province

Postal Code

Home Phone

Work Phone

Ext

Cell Phone

Email address

Preferred Method of Contact

Home Work Cell Email

Birthdate (DD/MM/YYYY)

Emergency Contact Name

Emergency Contact Number

Employment Status

Full time Part time Retired Other

Student Status

N/A Full time Part time

Referred by:

Do you have dental insurance?

yes no

If Yes, please fill out the following Insurance Information: Primary Insurance

Name of Policy Holder

Policy Holder's Birthdate (DD/MM/YYYY)

Employer

Insurance Company

Policy/Group #

ID/Certificate #

Division #

Secondary Insurance (if applicable)

Name of Policy Holder

Policy Holders Birthdate (DD/MM/YYYY)

Employer

Insurance Company

Policy/Group #

ID/Certificate #

Division #

If you DO NOT have insurance, please fill in for RESPONSIBLE PARTY FOR ACCOUNT

If someone other than the patient:

Parent Guardian Spouse Other

First name

Last name