Patient Registration

Please complete this confidential registration form, as your medical and dental health history are essential to determine the course or your treatment.

Patient Information

Insurance Information

Dental History

Have you ever had an unfavourable reaction after a dental treatment?

Are you currently in pain?

Are any of your teeth sensitive to the following?

Health History

Have you ever had excessive bleeding requiring special treatment?

Do you wear contact lenses?

Female patients, are you or could you be pregnant or nursing?

If pregnant, which month?