New Patient Contact Form


Welcome to Earlsbridge Dental

 

Mr Mrs Ms Dr First Name: ____________________ Last Name: _____________________

Preferred Name: __________________ Date of Birth: ______________ (MM/DD/YY) Male Female

Address: ______________________________________________________ Apt/Unit# _______________

City: __________________________ Province: ____________________ Postal Code: ________________

Home Telephone Number: _____________________

May we contact you at your workplace? Yes No Work Number: _______________ ext. _____

May we contact you on your cell phone? Yes No Cell Number: _________________________

May we contact you by e-mail? Yes No Email Address: _______________________

In case of an emergency – Please notify ____________________ Phone Number: _______________________

Physician’s Name: ____________________________ Phone Number: _______________________

Best way to contact you: Home# Work# E-mail Cell#

Best time to contact you: Morning Afternoon Evening

Preferred Method of Payment: Visa MasterCard Cash Debit

Driver’s License: ____________________ SIN#: _____________________________

Employer: _____________________________________ Position: ____________________________________

Marital Status: Single Married/Common Law Other

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Insurance Information

Primary Insurance Company Information:

Name of Insurance Policy Holder: ______________________ Date of Birth :_____________(MM/DD/YY)

Insurance Policy Holder: Self Parent/Guardian Other

Policy Holder Contact Phone Number: _____________________________ (if different from above)

Group Policy Number: ____________________________ I.D./Certificate Number: __________________

Secondary Insurance Company Information:

Name of Insurance Policy Holder: ______________________ Date of Birth :_____________(MM/DD/YY)

Insurance Policy Holder: Self Parent/Guardian Other

Policy Holder Contact Phone Number: _____________________________ (if different from above)

Group Policy Number: ____________________________ I.D./Certificate Number: __________________

Insurance Company Name: _______________________________________________

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Referral Information

How did you hear about us? (Check all that apply)

Direct Referral Name of Person: _______________________________________

Internet Web site/search engine source: ___________________________

Key words used: ________________________________________

Phone Book Publisher: Yellow Pages Can411 GoldBook

Other Please specify: __________________________________________

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