Patient Registration Form

Patient Information

*All fields required

Salutation*

First Name*

Last Name*

Date of Birth*

Registering for a child?*

Person responsible for account*

Other parental consent required*

Mother’s name*

Business Tel*

Father’s name*

Business Tel*

Email*

Home Phone*

Cell Phone*

Work Phone*

Address*

Street Address City Province Postal Code

I prefer appointment reminders by*

Whom may we thank for referring you?*

Are any other members of your family patients at our practice?*

Please list all family members*

Insurance Information*

Please complete the following if you have dental insurance

Name of insured/subscriber*

Date of Birth*

Patient's relationship to subscriber*

Place of Employment*

Insurance Company*

Policy/Group #*

Certificate/ID #*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*