Patient Registration Form Fill in the information Please enable JavaScript in your browser to complete this form. - Step 1 of 3Title: *Patient Name: *Preferred name: Date of Birth: *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Street address: *City: *province:postal code: Cellphone: *Home phone: Email address: Preferred method of contact: Emergency contact: Phone NumberRelationshipDental clinic NameName of your dentistLast Visit to a Dentist Last X-ray Last Extraction Reason for Visit Today *How Did You Hear About Us? Social MediaFriendGoogleotherInsurance information Primary insurance company: Relation to Insured SelfSpouseChildPolicy Plan/Group:Subscriber ID: Subscriber Name: Subscriber Birthday: Canadian Dental Care Plan: First Nation’s Status Number: Care Card Number If on Disability: Name of Medical Doctor: Doctor’s Office Name & Location: Are you currently under medical treatment? *YesNoMedication List: NextHave you ever been treated for or have any of the following? (Put √)Diabetic YesSinus TroubleYesHigh blood pressure YesDry mouthYesAutoimmune diseaseYeslow blood pressure YesHeart condition/Pace MakerYesStroke YesUlcers YesThyroid YesEpilepsy or seizures YesRepeat headaches YesHepatitisYesBruise easily /Bleeding problems YesJoint replacementYesRespiratory disease/ AsthmaYesHIV or any Sexually transmitted disease YesCancer treatmentYesPsychiatric TreatmentYesAlcoholism/Drug addictionYesAny allergy YesArthritis YesHearing loosYesDo you grind your teeth?YesDo your jaw joints crack, pop, or grate?YesAre your gums tender or sore? YesDo your teeth or dentures stain easily?YesDo you smoke?YesDo you have old dentures or implants? YesDo you suffer or want to mention any health concern that is not listed above?PreviousNextClaims Submission Authorization I hereby authorize Digital Smile Denture Clinic and its staff to submit my personal and insurance information to my dental insurance provider for the purpose of obtaining pre-authorization and payment directly to the clinic for services rendered. This authorization is provided for my convenience and does not release me from any financial responsibility for services received. PreviousSubmit
