Patient form

New Patient Registration

Complete this form before a first visit. It includes personal information, insurance details, dental concerns, medical history, and visit goals from the original Innovation Drive Dental form.

Back to Forms

Complete the form online for encrypted delivery to the private office inbox, or print it and bring it to the office.

Personal Information

Title First Name Last Name Initial Street Apt City Province Postal Code Home # Business # Cell/Other # Email Address Date of Birth Emergency Contact Relationship Emergency Phone

Are family members patients at our office? Names

Financial / Insurance Information

Primary subscriber relationship Primary subscriber Primary insurance company Primary policy # Primary ID # Primary employer Secondary subscriber relationship Secondary subscriber Secondary insurance company Secondary policy # Secondary ID # Secondary employer

Dental Concerns

How much? How many years?

Medical History

Any other health issues? Allergies to medications not listed above? Are you currently under the care of a physician? Family Physician Physician phone number Current prescription medications Complications following medical treatment? Complications following dental treatment? Weight Blood Pressure

Dental Visit Goals

How important is your dental health? (1 = not important, 10 = very important) When was your last dental visit? When was your last oral cancer screening? When was your last complete set of X-rays? What is most important about your dental visit today? If you could change anything about your mouth, teeth, or smile, what would it be?

Signature

Signature Date

Online submissions are encrypted and stored in the private Admin inbox. The office receives an email notification without medical or insurance answers. For urgent dental pain, call 905.264.0333.