South Ancaster Family Dental

New Patient Registration Form

21 Panabaker Drive, Unit 4, Ancaster, Ontario L9G 0A4      905-304-9555

Welcome to South Ancaster Family Dental

Please fill out the online patient registration form below prior to your first visit.

Patient Information (Confidential)

Name:
Current Date:
Street:
City:
Province:
Postal Code:
Home Phone:
E-mail:
Cell #:
Work Phone:
Employer:
Date of Birth:
Age:
Sex:
Marital Status:
Person to contact in case of emergency:
Phone:
If student, name of school:
Grade:
Whom may we thank for referring you?

Responsible Party

(Please complete all information if different from above)

Name:
Relationship to Patient:
Street:
City:
Province:
Postal Code:
Home Phone:
Date of Birth:
Employer:
Work Phone:

Is this patient currently a patient in our office?

Insurance Information

Name of Insured:
Date of Birth:
Employer / Group Policy Holder:
Insurance Year End:
Insurance Company:
Phone:
Group / Individual Policy #:
Certificate #:
Maximum Coverage:
% Used:

Percent Coverage:

Basic:
Major Restoration:
Orthodontics:

Do you have additional insurance? If yes, complete the information below.

Name of Insured:
Date of Birth:
Employer / Group Policy Holder:
Insurance Year End:
Insurance Company:
Phone:
Group / Individual Policy #:
Certificate #:
Maximum Coverage:
% Used:

Percent Coverage:

Basic:
Major Restoration:
Orthodontics:

Patient/Parent/Guardian Signature: