New Patient Form Adult

Name of Person on the original form*

Name of Patient*

Birth Date*

Marital Status*

Select a Choice*

Male
Female

Work Phone

Cell Phone

Email*

Employer*

Spouses Name*

Person to Contact in Case of Emergency*

University/College Student*

Full Time
Part Time
N/A

How would you prefer your appointment reminders?*

Via Mail
Phone Call
Text Message

Relationship to Patient*

Phone Number*

Do you have insurance?*

YES
NO

Do you have secondary insurance?*

YES
NO

Are you dissatisfied with the appearance of your smile?*

YES
NO

Do you have? (please check the following that apply)

If you could change one thing about your smile, what would it be?

What is your primary reason for booking the appointment is today?*

Have you had a negative experience, or is there something you would like us to know that will help us make your visit more comfortable?*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

INS Information

List Medications

Patient Medical History

Physician*

Physician's Office Phone*

Are you currently under any medical treatment?*

YES
NO

Have you been admitted to a hospital or needed emergency care during the past two years?*

YES
NO

Are you currently taking any medications, including over the counter medications?*

YES
NO

Have you ever had any complications following dental treatment?*

YES
NO

Are you pregnant?*

YES
NO

Do you have any allergies to medications?*

YES
NO

Do you have or have had any of the following? Please check all that apply.*

Patient Dental History

Check All That Apply*

Upload a Photo

We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.

I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Beacon Smiles Dental can electronically file dental claims on my behalf.

In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.*

*

I have read the above conditions of treatment and payment and agree to their content.

New Patient Form Additional Adult

Patient Medical History

Patient Dental History

Upload a Photo

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