Contact form 1 – Weston Dentistry

New Patient Form

Fields marked with an * are required

Title

First Name

Last Name

Date of Birth

Mobile

Home phone

Work phone

Email

Health fund name (for dental)

Occupation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency contact name

Name

Last Name

Emergency contact Mobile

Relationship to you (they are your?)

Medical History

Medical history (including allergies) & medication list- Please provide as much details as possible including information about past and upcoming surgeries or type NIL

Upload medication list here

Drag & Drop Files, Choose Files to Upload

Date

When was your last check-up & clean? (ie. 6 months, 12 months) *

Dental history- Please provide as much details as possible or type NIL

(ie. are Relationship

Dental Health

My gums bleed when I brush or floss
My teeth are sensitive to hot, cold or pressure
I grind or clench my teeth
I am interested in whitening
None of these apply to me

COVID-19

Have you already scheduled an appointment?

Yes.
No, I would like to receive an email to schedule an appointment.
No, I would like to receive a call to schedule an appointment.

Signature (please print name to sign)

First Name

Last Name

Checkboxes

I confirm that the information provided is correct and accurate. I am aware that I will be responsible for any and all fees associated with dental treatment on the day treatment is provided.

Medical History Form