New Patient Form

New Patient Form

01Patient Information

Please enter a valid preferred name.
Please enter a valid last name.
Please enter a valid date of birth.
Please enter a valid telephone number.
Please enter a valid home address.
Emergency Contact
Please enter a valid emergency contact name.
Please enter a valid emergency contact phone.

02Medical References

Dentist Information
Family Physician Information
Pharmacy Information
Do you have insurance coverage?

03Dental Information

Personal Health
Would you consider yourself to be in good health?
Do you smoke?
Any changes in health in the last year?
Have you had any allergic or adverse reactions to the following?
Do you have, or have had, any of the following conditions (please select all that apply):
Any medical conditions not listed:
Any medical conditions that run in your family?
Additional comments
Have you ever been hospitalized?
Are you pregnant?
Are you breastfeeding?
Approximate Due Date
Are you taking any vitamins or herbal supplements?
Recreational Drug Use
Approximate Weekly Alcohol Intake
Have you ever had root canal/endodontic therapy?
If yes:
How would you rate your previous experience?
Have you ever been recommended antibiotic coverage prior to surgery or dental procedures?
Have you ever had abnormal bruising/bleeding associated with a dental procedure?
Have you ever had an adverse reaction to dental freezing/local anesthetic?
Where would you rate your level of nervousness about dental treatment?
Current Medications
* If you require assistance in filling out this section, please bring your medication bottles to your appointment or, with your permission, we can call your pharmacy and request a list of current medications.

Suite 237 - 1338 Fourth Ave, St. Catharines

Monday - Friday: 8am - 5pm

Payment Options

Your consultation appointment will provide you with a predetermination outlining the costs of your upcoming treatment. Payment will be due at the time service is rendered. We accept Visa, Mastercard, Debit, American Express or cash payments. If you have insurance coverage, we can assist you in submitting your claim electronically or provide you with the forms necessary for you to submit independently.

Book a consultation with us today.

Request Appointment