Your Whitby dentist clinic specializing in family, emergency and cosmetic dentistry.

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Search for:

HOME
SERVICES
OUR TEAM
PATIENT CENTRE
BLOG
CONTACT US
BOOK AN APPOINTMENT

HOME
SERVICES
OUR TEAM
PATIENT CENTRE
BLOG
CONTACT US
BOOK APPOINTMENT

PATIENT INFORMATION FORM

Home
Whitby Dental Clinic
PATIENT INFORMATION FORM

"*" indicates required fields

CONFIDENTIAL PATIENT INFORMATION

PATIENT'S LAST NAME*

FIRST NAME*

MIDDLE INITIAL

PREFERRED NAME

PLEASE SELECT*

Adult

Child

Child under guardianship

DATE OF BIRTH*

MM slash DD slash YYYY

PATIENT'S GENDER*

Male

Female

NAME OF GUARDIAN, IF APPLICABLE

PATIENT ADDRESS*

MOBILE PHONE*

HOME PHONE

WORK PHONE

EMAIL*

By which way do you prefer to communicate with us? (Check more than one choice if necessary)*

Home #

Mobile #

Work #

EMAIL

MARITAL STATUS*

EMPLOYER

OCCUPATION

EMERGENCY CONTACT (Other than your family / home)

NAME*

RELATIONSHIP*

HOME PHONE*

WORK PHONE

HOW DID YOU HEAR ABOUT US? Please check referral

Website

Google

Flyer

Drive by

Facebook

FRIENDS/FAMILY (Please name to thank them)

INSURANCE COVERAGE*

Yes

No

If Yes, Please fill up the following details:

POLICY HOLDER

OCCUPATION

EMPLOYER

INSURANCE PROVIDER

POLICY #

CERTIFICATE/ID #

If not able to fill out the insurance coverage details please send a picture of insurance card by email to office or upload it here

UPLOAD COPY OF INSURANCE CARD

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.

GENERAL RELEASE

Yes*

I authorize Trinity Family Dental to submit any necessary pre-determinations inquiring further information about my dental benefits for recommended treatments.

Yes*

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history. I realize that the dentist is a general practitioner who offers main specialized treatments to patients. Should there be any change in my health status in the future, I will advise this dental office.

Yes*

I authorize the dentist to perform diagnostic procedures as my be required to determine necessary treatment. I understand that information provided from or to my doctor or another health care provider may be necessary.

Yes*

I consent to the responsibility for payment of the dental service for myself and my dependents is mine solely and I assume responsibility for fees associated with these services. I understand this office requires 2 business days notification to avoid any minimum charges.

Name of the authorizing person*

Professional Affiliations and Recognitions

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