Skip to content
(905) 579-5551
|
contact@trinityfd.com
Blogger
Facebook
X
Your Whitby dentist clinic specializing in family, emergency and cosmetic dentistry
Search for:
HOME
SERVICES
FAMILY DENTISTRY
COSMETIC DENTISTRY
CROWN & BRIDGEWORK
DENTURES
EMERGENCY DENTISTRY
INVISALIGN
DIGITAL X-RAY
ORAL CARE & COMPREHENSIVE EXAM
PREVENTIVE CARE
ROOT CANAL TREATMENT
SEDATION
SPORTS MOUTH GUARD & NIGHT GUARD
TEETH WHITENING
TOOTH EXTRACTION
OUR TEAM
Dr. ROLI VIG
Dr. SASAN
DR. BRIAN NGUYEN
DR. THEVAHI
STAFF
PATIENT CENTRE
BLOG
CONTACT US
BOOK AN APPOINTMENT
Search for:
HOME
SERVICES
FAMILY DENTISTRY
COSMETIC DENTISTRY
CROWN & BRIDGEWORK
DENTURES
EMERGENCY DENTISTRY
INVISALIGN
DIGITAL X-RAY
ORAL CARE & COMPREHENSIVE EXAM
PREVENTIVE CARE
ROOT CANAL TREATMENT
SEDATION
SPORTS MOUTH GUARD & NIGHT GUARD
TEETH WHITENING
TOOTH EXTRACTION
OUR TEAM
Dr. ROLI VIG
Dr. SASAN
DR. BRIAN NGUYEN
DR. THEVAHI
STAFF
PATIENT CENTRE
BLOG
CONTACT US
BOOK AN APPOINTMENT
HOME
SERVICES
FAMILY DENTISTRY
COSMETIC DENTISTRY
CROWN & BRIDGEWORK
DENTURES
EMERGENCY DENTISTRY
INVISALIGN
DIGITAL X-RAY
ORAL CARE & COMPREHENSIVE EXAM
PREVENTIVE CARE
ROOT CANAL TREATMENT
SEDATION
SPORTS MOUTH GUARD & NIGHT GUARD
TEETH WHITENING
TOOTH EXTRACTION
OUR TEAM
Dr. ROLI VIG
DR. SASAN
DR. BRIAN NGUYEN
DR. THEVAHI
STAFF
PATIENT CENTRE
BLOG
CONTACT US
BOOK APPOINTMENT
PATIENT INFORMATION FORM
Home
Whitby Dental Clinic
PATIENT INFORMATION FORM
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
*
Single
Never Married
Married
Widowed
Divorced
Separated
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
*
Submission Date
Professional Affiliations and Recognitions
Page load link
Go to Top
