Skip to content
Home
About Us
Why Us
Our Team
Our Office
Emergency Care
Services
Dental Emergency
Dental Cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
Additional Care
Sedation Dentistry
TMJ Treatment
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
dental cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Additional Care
Sedation Dentistry
TMJ Treatment
For Patients
Your First Appointment
Financial Solutions
Patient Forms
Contact Us
X
905-264-2297
book appointment
905-264-2297
book appointment
Home
About Us
Why Us
Our Team
Our Office
Emergency Care
Services
Dental Emergency
Dental Cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
Additional Care
Sedation Dentistry
TMJ Treatment
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
dental cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Additional Care
Sedation Dentistry
TMJ Treatment
For Patients
Your First Appointment
Financial Solutions
Patient Forms
Contact Us
X
Home
About Us
Why Us
Our Team
Our Office
Emergency Care
Services
Dental Emergency
Dental Cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
Additional Care
Sedation Dentistry
TMJ Treatment
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Urgent Dental Care
Root Canal Therapy
Wisdom Tooth Extraction
dental cleaning
Oral Exams & X-Rays
Dental Cleanings
Composite Fillings
Oral Cancer Screening
Gum Disease & Bad Breath
Periodontal (Gum) Care
Halitosis Treatment
Scaling & Root Planing
Restorative Dentistry
Tooth-Coloured Fillings
Crowns & Bridges
Dentures
Dental Implants
Cosmetic Care
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Gum Contouring
Orthodontics
Invisalign
Traditional Braces
Children’s Care
Sealants & Fluoride
Space Maintainers
Fillings & Dental Cavities
Preventive Care
Additional Care
Sedation Dentistry
TMJ Treatment
For Patients
Your First Appointment
Financial Solutions
Patient Forms
Contact Us
X
Patient Registration Form
Home
Patient Registration Form
Leave this field blank
Name
Date of Birth
Title
Dr.
Mr.
Mrs.
Ms.
Registering for a child?
Yes
No
If Patient is a child
Person responsible for account:
Other parental consent required:
Yes
No
Mother's Name
Phone Number
Father's Name
Phone Number
Contact Information
Email
Address
Phone Number
In case of emergency, please notify:
Relationship to the Patient
Phone Number
Contact Options
I prefer appointment reminders by
Phone
SMS
Email
Whom may we thank for referring you?
Are any other members of your family patients at our practice?
Yes
No
If yes, please list all family members
Insurance
Do you have Dental Insurance? (optional)
Yes
No
Please complete the following if you have dental insurance
Name of insured/subscriber (optional)
Date of Birth (optional)
Patient's relationship to subscriber (optional)
Yes
No
Place of Employment (optional)
Insurance Company (optional)
Policy/Group Number (optional)
Certificate/ID # (optional)
I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations (optional)
Yes
No
Medical History
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please complete the entire form.
Are you being treated for any medical condition at present or any time within the past year?
Yes
No
Not Sure/Maybe
When was your last medical checkup? (optional)
Has there been any changes in your general health in the past year?
Yes
No
Not Sure/Maybe
If yes, please specify (optional)
Are you taking any prescription, non-prescription medications, or herbal supplements?
Yes
No
Not Sure/Maybe
Do you have any allergies?
Yes
No
Not Sure/Maybe
If yes, please specify
Medications
Latex/Rubber Produucts
Other
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Yes
No
Not Sure/Maybe
If yes, please list below with approximate dates (optional)
Do you have or have you ever had asthma?
Yes
No
Not Sure/Maybe
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure/Maybe
Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?
Yes
No
Not Sure/Maybe
Do you have a prosthetic or artificial joint?
Yes
No
Not Sure/Maybe
Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Yes
No
Not Sure/Maybe
If yes, please specify (optional)
Have you ever had hepatitis, jaundice, or liver disease?
Yes
No
Not Sure/Maybe
Do you have a bleeding problem or bleeding disorder?
Yes
No
Not Sure/Maybe
If yes, please specify (optional)
Have you ever been hospitalized for any illnesses or operations?
Yes
No
Not Sure/Maybe
Do you have, or have ever had any of the following? Please check
Chest pain/angina
Osteaporosis Medications
Mitral Valve Prolapse
Shortness of Breath
Rheuumatic Fever
Heart Attack
Stroke
Cancer
Pacemaker
Lung Disease
Heart Murmur
Arthritis
Steriod Theraphy
Diabetes
Tuberculosis
Drug/Alchohol Dependency
Seizures
Thyroid Disease
Stomach Ulcers
Kidney Disease
None of the above
Are there any conditions/diseases not listed that you have or have had?
Yes
No
Not Sure/Maybe
If yes, please specify (optional)
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?
Yes
No
Not Sure/Maybe
If yes, please specify (optional)
Do you smoke or chew tobacco products?
Yes
No
Not Sure/Maybe
Are you nervous during dental treatment?
Yes
No
Not Sure/Maybe
For women only: Are you pregnant or breastfeeding?
Yes
No
Not Sure/Maybe
If yes, when is your expected delivery date?
Yes
No
Not Sure/Maybe
Dental History
Do you have any specific dental concerns? Please list: (optional)
When was your last dental appointment? (optional)
How often do you see the dentist?
Not Applicable
Every 3 months
Every 4 months
Every 6 months
Only whem something is bothering me
Is there anything about the appearance of your teeth that you would like to change? (optional)
Have you ever whitened (bleached) your teeth?
Yes
No
Not Sure/Maybe
Do you feel uncomfortable or self-conscious about the appearance of your teeth? (optional)
Have you been disappointed with the appearance of previous dental work? (optional)
Submit
Scroll to Top
