Dentistry on Danforth    Back to Forms

Confidential Information Questionnaire

249 Danforth Avenue, Toronto, ON, M4K 1N2      416-466-4422

Welcome to Dentistry on Danforth

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

General Information

*Patient's Full Name:
*Preferred Name:
Patient is a(n):
*E-mail:
*Date of Birth:
Gender (Please fill in - not required):
Guardian's Name:

Contact Information

*Street:
*City:
*Province:
*Postal Code:
Tel. Home:
Tel. Cell:
Tel. Work:
Ok to call work?:

Additional Information

Marital Status:
Patient's/Guardian's Employer:
Occupation:
Reason for today's visit:
Dental problem for immediate treatment?:
Emergency Contact:
Relationship:
Work #:
Home #:
Other family members that are patients here:
Who may we thank for the referral?:

Insurance and Financial Information

Person responsible for account:
Name:
Work #:
Home #:
Insurance Coverage:
Patient's Relationship to Subscriber:
Subscriber's Name:
Birth Date:
Insurance Company:
Employer:
Group/Policy #:
Division #:
Certificate/ID #:
Secondary Insurance Coverage:
Patient's Relationship to Subscriber:
Subscriber's Name:
Birth Date:
Insurance Company:
Employer:
Group/Policy #:
Division #:
Certificate/ID #:
Method of Payment:

Release

I am financially responsible for any balances due on the day of treatment, and authorize the dentist to release any information for insurance claims to the insurance company on my behalf. In consideration of the services rendered to me by this office I am obligated to pay said office in accordance with its credit terms and policy. I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

I also authorize the dentist to use my email and or cell phone number to confirm/re-schedule appointments, send enewsletters or any vital electronic information that may help me keep informed about my oral health. I understand that I can unsubscribe at any time.

Patient/Parent/Guardian Signature: