New Patient Form PATIENT INFORMATION First Name Last Name Email * Date of Birth * MM DD YYYY Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country EMERGENCY CONTACT First Name Last Name Phone (###) ### #### Insurance Information * Do you have Dental Insurance? Yes No Unsure Insurance Company Name: Certificate / Policy ID Number Policy Holder Full Name Policy Holder D.O.B * MM DD YYYY MEDICAL INFORMATION Family physician name First Name Last Name Family physician number (###) ### #### Date of previous visit MM DD YYYY Dentist name First Name Last Name Dentist phone number: (###) ### #### Date of previous visit MM DD YYYY Have you had dental x-rays taken within the last year? Yes No Do you have any of the following conditions? Heart disease High blood pressure Hepatitis A/B/C Cold sores HIV or AIDS Asthma Stroke Diabetes Epilepsy or seizures Snoring Gastrointestinal disorder Respiratory Disease Kidney disease Arthritis Mouth cancer Earaches Neck or shoulder pain Sore or tending gums TMJ Grinding teeth Heart Murmur Fainting spells Anemia Dry mouth Checkbox * Dentures on Yonge & Implant Solutions is dedicated to safeguarding your privacy. We will use your personal information solely to manage your account and deliver the products and services you have requested from us. By checking this box, I acknowledge that all patient information forms will be kept private and confidential by Dentures on Yonge & Implant Solutions, in compliance with applicable privacy laws and regulations. I agree to the terms Thank you for filling out the new patient form. A member of the Dentures on Yonge & Implant Solutions team will be in contact with you shortly.
