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  • HOME
  • PATIENT CENTRE
    • Patient Forms
      • New Patient Form
      • Medical History Update
      • 5-Year Medical History Update
      • Covid-19 Patient Screening Form
      • COVID-19 Pandemic Dental Risk Consent
  • SERVICES
    • Emergency Services
      • Emergency Dental Exams
      • Dental X-Rays
      • Cuts & Lacerations
      • Dental Root Canal
      • Dental Filling Cavities
      • Crowns & Bridges
      • Repair Broken Teeth, Fillings, Crowns & Dentures
      • Replacement Of Fillings & Crowns
      • Removal Of Foreign Bodies
      • Treatment Complications
    • Cleaning and Prevention
    • Complicated Tooth Extractions
    • Dental Restorations
    • Cosmetic Dentistry
    • Periodontal Disease
  • FOR STUDENTS
  • BLOG
    • News
  • SERVICE AREAS
    • Waterloo
      • Beechwood Waterloo Ontario
      • Beechwood West-Ontario
      • Clair Hills-Ontario
      • Colonial Acres-Ontario
      • Upper Beechwood-Ontario
      • View All Areas
  • Book An Appointment
New Patient Form

New Patient Form

Waterloo Emergency Dental Centre

258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505

DD slash MM slash YYYY
Patient Name(Required)
Date of Birth(Required)

Gender

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
What pronouns do you prefer that we use when referring to you? (check all that apply)

Contact Information

Address(Required)
Family Physician(Required)
In Case of Emergency, We should notify:(Required)

Payment Information

Party Responsible for Payment

Insurance Information

*Please note, patient is responsible with providing us a copy of their insurance card(s).*

Primary

Name of Insured
Insured's Birth Date

Secondary

Name of Insured
Insured's Birth Date

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic
Aspirin/Advil
Codeine
Latex
Local Anesthetics/Novocain
Other

Have you ever had any of the following? Please check those that apply:

Neural
Cardiovascular
Pulmonary
Infectious
Immune
Neoplastic
Digestive
Inflammatory
Other
If you had any surgeries please specify the surgery date and information.
Due Date
When did you quit?
Whom may we thank for referring you to our practice ?(Required)

Consent for Services & Office Agreement

* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage.

It is my responsibility to ensure that the treatment I request is covered. However, Waterloo Emergency Dental Centre will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Waterloo Emergency Dental Centre has NO knowledge of what is covered by my insurance plan. If I have a booklet, Waterloo Emergency Dental Centre will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Waterloo Emergency Dental Centre will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* Waterloo Emergency Dental Centre also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

* Waterloo Emergency Dental Centre will always make every attempt to see emergency cases promptly.

* Waterloo Emergency Dental Centre will accept Visa, MasterCard, debit and cash.

* Waterloo Emergency Dental Centre will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that Waterloo Emergency Dental Centre has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.
Consent(Required)
DD slash MM slash YYYY

About Our Dentist Office

Waterloo Dental Centre specializes in providing excellent emergency and non emergency dental care to patients in the Waterloo, Ontario area. Many dental problems need to be addressed immediately to prevent the condition from worsening, which is why it is our mission is to serve you as quickly as possible, to avoid any pain or increase in damage.

Waterloo Dental Centre

  • 258 King Street North, Unit #7
    Waterloo, Ontario, Canada, N2J 2Y9
  • (519) 883-0505
  • SMS (519) 904-4431
  • [email protected]

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