We are always welcoming new patients.

Please take a moment to provide us with the following information so we can ensure your SCD experience is an easy one.

Adult Patient Registration Form (Existing Patient)

Patient Registration Form - Adult (Existing Patient)

Personal Information

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

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

Medical History

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?
Sign Here

Electronic Submission and Communication Consent

Book an Appointment

Fill the form below to schedule your appointment or call (647) 953-4630 for emergency.
Slider Form