4841 Yonge St, North York, ON

(416) 224-8375

info@sheppardcentre.dental

Patient Registration

Welcome to Sheppard Centre 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.

Salutation

First Name

Last Name

Address

Street Number

Street Address

City

State

Country

Zip Code

Phone Number

Date of Birth

Family Physician

Physicians Phone Number

Emergency Contact

Emergency Contact Phone Number

Relationship

Employer

Occupation

Spouse's First Name

Spouse's Last Name

Spouse's Phone Number

Spouse's Employer

Spouse's Occupation

Drivers License Number

Credit Card Number

Credit Card Type

Expiry Date

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

SIN/Certificate #

Group Policy #

Secondary Insurance Company

Employee Name

SIN/Certificate #

Group Policy #

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

4841 Yonge St, North York, ON

(416) 224-8375

info@sheppardcentre.dental

Mon: 8:00 A.M. – 7:00 P.M.
Tue: 8:00 A.M. – 7:00 P.M.
Wed: 8:30 A.M. – 7:00 P.M.
Thu: 8:00 A.M. – 7:00 P.M.
Fri & Sat: 8:30 A.M. – 4:00 P.M.

Services

Contact Us

Book an Appointment

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