New Patient Form

CONTACT INFORMATION
UNDER 18 YEARS OLD (to complete only if the patient is under 18 years old)
REFERRAL INFORMATION
MEDICAL HISTORY
DENTAL HISTORY

CONSENT FOR SERVICE

  • I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.
  • I understand that the practice requires as minimum 24 hours notice if I need to cancel my schedules appointment and that a cancellation fee of $50.00 could be incurred if I fail to do so.
  • I hereby consent to use of any study models, x-rays, computer images and photographs at various dental seminars, lectures, and publications that the dentists may author.
  • I am aware that payment is required on the day of the treatment