New Patient Intake Form
Required fields are denoted with *.
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Insurance and Credit Card Details
If you do not have any insurance benefits to provide, please ignore the following sections.
As a courtesy to our patients, our practice accepts assignment of benefits from most dental insurance companies. We do require a credit card to be left on file for this option to cover any remaining portions not covered by your insurance.
Your credit card infomation will be securely stored and encrypted on our local server.
Card Type
Mastercard
Visa
American Express
Discover
JCB
Card Number
Expiration date
CVV/CVC
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
