New Patient Registration | Bramalea Smiles Dentistry

Personal Information
Insurance Information
Medical History
Dental History
Patient Certification and Consent

Personal Information

Tell us who you are and how to reach you.

Step 1 of 5

First Name *

Last Name *

Gender

M F

Birth Date *

Address *

City *

Province

Postal Code *

Cell Ph.

Home Ph.

Email *

Preferred Contact Method

How Did You Hear About Us

Emergency Contact and Relations *

Name, relationship and phone number.

Insurance Information

Leave blank if you do not have dental insurance.

Step 2 of 5

Primary Subscriber Name

Secondary Subscriber Name

Primary Insurance Name

Secondary Insurance Name

Primary Employer Name

Secondary Employer Name

Primary Group # / Plan # / Contract #

Secondary Group # / Plan # / Contract #

Primary Subscriber ID #

Secondary Subscriber ID #

Relationship to the Primary Subscriber

Self Spouse Child

Relationship to the Secondary Subscriber

Self Spouse Child

Others

Dental History

A quick picture of your dental care so far.

Step 4 of 5

1. Last dental visit?

What was done at that visit?

Have you had any x-rays done at that visit?

Yes No

2. How frequently do you see your dentist?

3. What are your present dental concerns?

4. Have you ever lost a tooth/teeth in an accident, decay or gum disease? *

Yes No

5. How do you describe your dental health at present? *

Good Fair Poor

Patient Certification and Consent

Please read, then sign with your mouse or finger.

Step 5 of 5

Signature *

Sign here with your mouse, finger or stylus

Your signature is attached to the PDF sent to the clinic.

Date *

Your answers are sent straight to the clinic and are treated as confidential health information.