New Patient Form

SapphireDentalCentre

Welcome to our office! To assist us in serving you, please complete the following confidential information.

PATIENT INFORMATION

Use this form to screen patients before their appointment and when they arrive for their appointment

Patient Last name

First name

Sex

Birth Date

Home Phone

Cell Phone

E-Mail

Address

City

Prov.

Postal Code

Employer/School

Occupation

Work Phone

Spouse Name

Spouse Employer

Whom may we thank for referring you to our office?

Emergency Contact Name

Relation

Phone

DENTAL HISTORY

Reason for today’s visit

Former Dentist Name

Date of last dental visit

Date of last cleaning

Date of last dental X-ray

Do you have or have you had any of the following? (Please check any that apply)

Do you have any dental related issues/concerns not listed above?


MEDICAL HEALTH HISTORY

Are you allergic to, or have you reacted adversely to:

Other:
Are you taking any of the following?

Other:
Women:
May be pregnant, expected due date:
Name of the Physician:
Phone number:
Do you have any disease, condition, or problem not listed above?
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist.

Signature of patient (or parent)

Date:

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Address

433 Steeles Ave E Unit 102 Milton, ON L9T 8Z4

905 878 - 8760 Ext 1

Call us today!

Appointment Booking

info@sapphiredentalcentre.com