Patient Registration Form Family Dentistry Serving Courtice, Oshawa and Durham Region 5-1414 King St. E 905-434-5500 Thank you for choosing King Town Dental Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please carefully review information before progressing to the next section. Do not refresh the page or you will need to restart. - Step 1 of 6Patient DemographicsName *FirstMiddleLastPreferred NameSex *MaleFemalePrefer not to sayStatus *SingleMarriedChildOtherBirthday *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Primary Phone Number *Work PhoneInclude your extension if applicable.Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHow did you hear about us? *Emergency Contact InformationName *FirstLastPhone *Relationship to you *i.e. Partner, Mother, SisterNextEmployment InformationEmployer NamePhoneAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePrevious PageNextAre you a parent/guardian or care worker for the patient? *YesNo, filling out form for myself.Responsible PartyName *FirstMiddleLastPreferred NameSex *MaleFemaleStatus *SingleMarriedChildOtherBirthdate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number *Email *Best Time to CallMain / Cell Phone *Work PhoneExtensionAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeDo you have dental insurance? *YesNoPrevious PageNextPrimary Dental InsuranceName *FirstMiddleLastInsured's Status *SingleMarriedChildOtherPhone *ID# *Group# *Insured's Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeInsurance Plan Name *Insured's Employer Name *Insured's Employer Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeInsurance AuthorizationI authorizeBy checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I understand that I am financially responsible for all chargers whether or not paid by insurance.What is your immediate concern? *Previous Dentist Name *FirstLastDate of most recent dental exam and dental x-raysMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there anything about the appearance of your smile that you would like to change?Check all that apply.Had complications from past dental treatmentHad trouble getting numbHad any reactions to local anestheticHad/have braces, orthodontic treatmentYou experience dry mouthAny teeth sensitive to hot, cold, biting, sweets or avoid brushing any part of your mouthFood gets trapped between any teethHave you ever whitened or bleached your teethHave you experienced popping and/or clicking of your jaw jointYou have difficulty chewingYou clench or grind your teethYou wear or have worn a bite applianceGums bleed when brushing or flossingTreated for gum disease or were told you have lost bone around your teethNoticed an unpleasant taste or odor in your mouthExperienced gum recessionHad any teeth become loose on their own (without injury)Experienced a burning sensation in your mouthYou snore or wake up frequently during the nightIf any of the checked boxes need further explanation, please describe.Previous PageNextBy providing my electronic signature below I hereby consent to treatment as recommended by my provider. This consent shall be considered in effect until rescinded or revoked.Signature * Clear Signature Previous PageNextFinancial Policy AcknowledgementPayment is due at the time of service. Insurance estimates are not a guarantee of payment. The patient is responsible for payment for services regardless of insurance coverage. By providing my electronic signature below, I attest that I understand and agrewe to the above financial policySignature * Clear Signature Submit King Town Dental Dr. Sabrina Bedi, DDS Courtice Dentist5-1414 King St. E (external map)Townline Centre 905-434-5500 Opening Hours Same Day Emergencies Accommodated Monday | 9am - 6pm Tuesday | 9am - 6pm Wednesday | 10am - 7pm Thursday | 10am - 7pm Referring Offices Patient Information Dental Treatments Canadian Dental Care Plan Contact Us Financial Policy FollowFollowFollow
