NEW PATIENT FORM – English
WELCOME TO BATHURST COLLEGE DENTISTRY
To serve you better, we ask that you complete the following patient form.
If assistance is needed please call 416 925-0154.
All sections marked with an asterisk *
are mandatory to be completed.
PRIMARY CONTACT (Only complete, if different from above).
Dental insurance is considered a method of payment. However, the patient themselves or whomever is responsible for financials (as listed above), is required to pay all unpaid balances not covered by insurance. Initial here to confirm you agree.
All information is encrypted
Select all applicable boxes.
Select all applicable boxes & enter approximate dates.
No fee for cancellations with notice greater than 48 hours.
Cancellations under 48 hours are subject to a fee of $50 for each hour missed.
I, the undersigned, understand that the information contained in the medical and dental history sections of this form are important to my treatment. I certify that all the information that I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor and/or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibilities for fees associated with my dental treatment or dental diagnostic procedures. By initialing this digital document, I consent to the collection of my personal information via an electronic device. I agree that my initials will be legally adopted as my signature and that this form is legally binding. Additionally, I agree that my typed name and initials will act as official representatives of my personal signature.
THANK YOU for submitting the new patient form. (English Version)