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?*

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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