METROTOWN DENTAL CLINIC

NEW PATIENT INFORMATION FORM

Name:

Date:

Address:

City:

Prov:

Postal Code:

Home phone:

Work phone:

Cell phone:

Email:

*Opt in Newsletter:

Yes

Date of birth:

Sex:

If child, parent's name:

Person to contact in case of emergency:

Relationship to Patient:

Phone:

If student, name of school:

Grade:

Whom may we thank for referring you:

Credit Card Info:

Visa

AMEX

Card #:

Expiry Date:

CSV #:

Responsible Party (Please complete all information if different from above)

Name:

Relationship to Patient:

Address:

City:

Prov:

Postal Code:

Home phone:

Work phone:

Cell phone:

Date of birth:

Is this person currently a patient in our office?

Yes

Insurance Information

Name of insured:

Date of birth:

Insurance Company:

Insurance year end:

Policy #:

ID/Certificate #:

Annual maximum:

Annual deductible:

Percentage coverage:

Basic:

Major:

Ortho:

Recall frequency:

Polish/fluoride frequency:

Scaling/Root Planing limit:

#Units:

Do you have additional insurance?

Yes

If yes, complete the following:

Name of insured:

Date of birth:

Insurance Company:

Insurance year end:

Policy #:

ID/Certificate #:

Annual maximum:

Annual deductible::

Percentage coverage:

Basic:

Major:

Ortho:

Recall frequency:

Polish/fluoride frequency:

Scaling/Root Planing limit:

#Units:

Once your appointment is set, a chair is booked and your dentist and staff are scheduled. If you are unable to keep your appointment, you must inform us at least 2 business days in advance to avoid a charge. Missed appointments can result in $100 fee.

Signature of patient or parent if minor (draw with mouse/stylus/finger to sign):

Reset Signature

HIPAA Compliant