Patient Registration - Children (New Patient)

Personal Information

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

First Name

Last Name

Date of Birth

Place of Birth

Address

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

Family Physician

Physician's Phone Number

Health Card #

Referred to us by

TO ESTABLISH YOUR ACCOUNT, PLEASE PROVIDE THE FOLLOWING INFORMATION:

Mother's Name

Residential Number

Business Number

Cellphone Number

E-mail

Father's Name

Residential Number

Business Number

Cellphone Number

E-mail

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

Do you have an insurance?

Yes

Do you have a secondary insurance?

Yes

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 child's last dental visit?

What was done at the time?

When was your child's last cleaning and fluoride?

When was the last time your child had dental x-rays?

Has your child ever had any of the following?

Orthodontic Treatment

Oral Surgery

None

Does your child have any of the following concerns when smiling?

White Teeth

Crowding

Other

None

If you checked "Other", please specify.

Medical History

When was your child's last medical checkup?

When was your child's last visit to a physician?

Are there any conditions or diseases not listed above that your child has or has had?

Yes

If you answered yes, what are those?

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

Yes

If you answered yes, what are those?

Other Comments

To the best of my knowledge, the above information is correct.

Signature of Parent

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
Toothache
Abscess
Filling
Freezing
Cold Sores

	Yes	No	Maybe
Nail Biting
Grinds Teeth
Thumb/Finger Sucker
Bottle in bed
Is your child nervous about dental treatments?

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

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.

Child Patient Registration Form (New Patient)