Baseline Dental Centre | New Patient Form
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New Patient Form

NEW PATIENT FORM

We understand that your time is valuable and in order to streamline your first visit, simply complete at your convenience, prior to your appointment. If you would rather complete the forms at our office, we ask that you kindly arrive 15 minutes before your scheduled appointment. You will enjoy a complimentary beverage, and feel free to ask for our assistance with any questions you might have.

REFERRAL INFORMATION

Patient Information

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Insurance Information

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FINANCIAL INFORMATION

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On a scale of 1 to 10, with 10 being the highest rating
On a scale of 1 to 10, with 10 being the highest rating

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
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GENERAL RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario
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