Patient Registration Form - Adult (New Patient)

Personal Information

This form must be completed in full. Please use N/A if not applicable.

Salutation

First Name

Last Name

Address

Suite #, House #, Street Name, City, Postal Code

Residence Number

Cell Number

Date of Birth

Place of Birth

Family Physician

Physician's Phone Number

Health Card #

Referred to us by

Emergency Contact

Emergency Contact Number

Relationship

TO ESTABLISH YOUR ACCOUNT, PLEASE PROVIDE THE FOLLOWING INFORMATION:

Employer

Occupation

Spouse's First Name

Spouse's Last Name

Date of Birth

Spouse's Phone Number

Spouse's Employer

Spouse's Occupation

Credit Card Number

Credit Card Type

Expiry Date

CVV

I hereby understand and agree that if any amount remains unpaid on my account, I authorize Sheppard Centre Dental to debit my credit card for the unpaid balance.

Insurance Information

Primary Insurance Company

Employee Name

Member ID

Group Policy #

Secondary Insurance Company

Employee Name

Member ID

Group Policy #

I authorize release to my insurance company and/or plan administrator, the information contained in claims submitted electronically.

Dental History

Former Dentist Name

Phone Number

Location

When was your last dental visit?

What was done at the time?

When was your last scaling (cleaning)?

When was the last time you had dental x-rays?

Have you ever had any of the following?

Orthodontic Treatment

Oral Surgery

Periodontal Surgery

None

Do you have any of the following concerns when you smile?

Crowding

White Teeth

Other

None

If you answered "Other" when asked if you have any concerns when you smile, please specify.

Are you having pain or discomfort at this time?

Yes

If you answered yes to having pain or discomfort at this time, please specify where.

Do you have problems with your jaw?

Yes

If you indicated experiencing any issues with your jaw, kindly provide details here.

Do you drink coffee/tea?

Yes

If you answered yes to drinking coffee/tea, please specify how often.

Do you eat sweets?

Yes

If you answered yes to eating sweets, please specify how often.

How often do you brush your teeth a day?

Never

1-2

3-4

Medical History

When was your last medical checkup?

When was your last visit to a physician?

	Yes	No	Maybe
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement of a heart valve, an infection of the heart (i.e., infective endocarditis), a heart condition from birth (i.e., congenital heart disease) or a heart transplant?
Have you ever been advised to take antibiotics prior to dental treatment?
Do you have or have you ever had jaundice, hepatitis or liver disease?
Have you ever been told that you should not give blood?
Do you have any conditions that could affect your immune system (i.e., HIV Positive, AIDS, Leukemia, etc.)?
Do you have a tendency to bruise easily or bleed for a prolonged period fo time after being cut?
Do you smoke or chew tobacco products?

Are you breastfeeding or pregnant ? (For women only)

Yes

Not sure/Maybe

If you answered yes, what is the expected delivery date?

Are there any conditions or diseases not listed above that you have or have had?

Yes

Not sure/Maybe

If yes, what are those?

Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)

Yes

Not sure/Maybe

If you answered yes if there's any diseases or medical problems that run in your family, please specify

Patient Signature

Sign Here

Date

Electronic Submission and Communication Consent

By completing and submitting this New Patient Registration Form, you are providing your consent for the electronic submission of your personal and health-related information. Your data will be securely transmitted to Sheppard Centre Dental and will be used to facilitate your personalized dental care.

In accordance with local and federal privacy laws, we uphold rigorous measures to protect the privacy and security of your information. Your data will be stored and managed securely, with access limited to authorized healthcare professionals at Sheppard Centre Dental.

Additionally, by providing your consent, you are also agreeing to receive communications from Sheppard Centre Dental. This may include appointment reminders, updates on your treatment plan, and other relevant health information. These communications may take place via phone calls, emails, text messages, or through our secure patient portal, in line with privacy regulations.

Please remember, you have the right to withdraw this consent at any time by directly contacting Sheppard Centre Dental.

By clicking the check box, you confirm your understanding of these terms and conditions and your consent to the electronic submission of your data, as well as to receive electronic communication from Sheppard Centre Dental.

If you have any questions or concerns, please do not hesitate to contact us. We greatly value your trust and are committed to upholding the highest standards of patient privacy and data security.

	Yes	No	Maybe
Do your gums bleed when you brush?
Are you nervous about dental treatments?
Have you noticed any loosening of your teeth?
Does food tend to get caught between your teeth?

Yonge Sheppard Centre Mall, 111 - 4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

111-4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

New Patient

Personal Information

This form must be completed in full. Please use N/A if not applicable.

TO ESTABLISH YOUR ACCOUNT, PLEASE PROVIDE THE FOLLOWING INFORMATION:

Insurance Information

Dental History

Medical History

Electronic Submission and Communication Consent

Services

Contact Us

Book an Appointment