New Patient Form

PATIENT INFORMATION

Last Name:

First Name:

Birth Date:

Preferred name:

Marital status:

Address:

City:

Postal Code:

Res. Phone:

Employer:

Bus. Phone:

E-mail address:

Cell Phone:

Physician name:

Telephone:

In case of emergency, please notify:

Relationship:

Telephone:

Whom may we thank for referring you?:

How Did You Hear of Us?

Other:

Other family members seen here:

INSURANCE INFORMATION

Please give your insurance card to the receptionist

INSURANCE #1

Subscribers Name:

Policy Holder's Birth Date:

Member ID:

Carrier:

Group/Policy Number:

Employer:

INSURANCE #2 (if applicable)

Subscribers Name:

Policy Holder's Birth Date:

Member ID:

Carrier:

Group/Policy Number:

Employer:

PATIENT CONSENT

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary and I consent to release this information. I assume full responsibility for payment of dental services provided for myself and my dependants, and authorize release to my dental benefits plan administrator of information contained in claims submitted. This authorization shall continue in effect until the undersigned revokes the same.

Patient's (Parent) Signature:

Date:

New Patient Form

PATIENT INFORMATION

INSURANCE INFORMATION

INSURANCE #1

INSURANCE #2 (if applicable)

DENTAL HISTORY

MEDICAL HISTORY

PATIENT CONSENT

Why Choose Canterra Dental

Direct Insurance Billing

Welcoming New Patients

Convenient Hours

Modern Digital Dentistry

Parking Available

Families Welcome

Contact Our Friendly Dental Team

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Dr. Dennis Leung, DDS

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