New Patient Forms - WHITBY, ONTARIO, CANADA

New Patient Forms

Please click the button to download and print the new patient form you will need to bring for your first visit. Please complete and sign this form, and bring it along with your insurance card and booklet to your appointment.

Alternatively, Please Fill Out the Form Online

Online Patient Forms

Patient Contact Information


Insurance Information

Primary Insurance Company

Secondary Insurance Company (if applicable)


Referral Information

How did you hear about us?

WebsiteInternetYellow PagesReferral



Dental History

Please check any of the following that may apply to you

Sensitivity Grinding or clenching teethTooth Pain or Discomfort While ChewingBleeding, swollen or irritated gumsHeadaches, earaches, or neck painLoose or shifting teethJaw Joint Pain (clicking/cracking)Bad breath or taste in the mouthBroken Teeth or Fillings

nitrous oxide (laughing gas)oral medication

Medical History

Please check any of the following that apply to you:

AIDSDiabetesHigh Blood PressureRheumatic FeverAllergiesEmphysemaHIV PositiveSeizuresAnaemiaExcessive BleedingJaundiceSnoring/Sleep ApneaArthritisFaintingKidney DiseaseStomach ProblemsArtificial JointsGlaucomaLiver DiseaseStrokeAsthmaHeart ConditionsLow Blood PressureThyroid DiseaseBlood DisordersHeart MurmurPacemakerTuberculosisCancerHeart DiseasePregnant UlcersChemotherapyHepatitis A, B or CRespiratory Problems

Do you have any allergies

AspirinCodeinePenicillinSulphaDrugsLocalAestheticLatex

READY FOR THE SMILE OF YOUR DREAMS?

Contact our team today!