• (905)567-6757
  • 6733 Mississauga Road, Suite 102
    Mississauga, ONL5N6J5
  • Toll Free: 1(866)567-3368(DENT)
  • Fax: (905)567-8134
  • Email: info@rdentists.com
  • Website: www.rdentists.com

New Patient Form

  • Date Format: MM slash DD slash YYYY
  • MEDICAL ALERT

  • WELCOME TO OUR OFFICE

  • The following information is required by the dentist to assist in proper diagnosis and treatment. Please feel free to ask the receptionist for help in completing this form. PLEASE PRINT.
  • Date Format: MM slash DD slash YYYY
  • NEW PATIENT INFORMATION
  • We love to get to know our patients, and we also want to make your dental experience as pleasant as possible. For this, we want to get to know you! The following questions are optional but we hope by answering them we can get to know you better and find something in common 🙂

  • MEDICAL HISTORY(this information will remain confidential)

  • GENERAL RELEASE: I, the undersigned, understand that the information contained in the medical history portion of this chart is important to my treatment. I certify that all information is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health providers as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine the necessary treatment. I understand that it is my responsibility to pay for dental treatments for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

  • Updates

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY