Welcome To"*" indicates required fields Name* First Last Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell Phone*Work PhoneEmployer*Date of Birth* MM slash DD slash YYYY Email Address* Do you use Dental Insurance?* Yes NoEmployer*Birthday of Policy holder if not yourself :* MM slash DD slash YYYY Name of Insurance Company:*Plan ID No.*Subscriber No.*Did you find us by?* Google Search/Website Print Advertisement Our SignsWhich method is the best and MOST RELIABLE way to get in touch with you (you are sure to get the message promptly). PLEASE CIRCLE and note if there are specific times or days.* Home Phone Work Phone Cell Phone Text Messaging EmailSpecific times or days:*Emergency Contact Name*Phone Number*Medical Conditions/Diagnosis:*Please note: we are pleased to provide our patients with assignment (direct billing) from the insurance provider. It may be necessary for you to collect the details of your policy due to privacy. The more information we have, the more accurately we will be able to estimate possible out of pocket expenses for your required treatment. Dr. Singer will thoroughly review your medical history, please list the following:If you were referred by an existing patient, who can we thank?*Prescription Medication:*Allergies (Food, Medicine or other):Surgeries:*Physician/Specialist Name (Date of last Visit):*How can we help you today?* Comprehensive Care/New Patient Specific ConcernMissing teeth that should be replaced to preserve bone and tooth position.* Yes NoI have spontaneous/unprovoked/ tooth pain, or pain that wakes me from sleep.* Yes NoI have pain in my jaw joint. (Head/Neck aches associated).* Yes NoI have pain when biting into food that is room temperature.* Yes NoI have pain to cold or hot food or drinks.* Yes NoFood catches between my teeth.* Yes NoI would like my teeth to be straiter/more aligned.* Yes NoI would like my teeth to be shaped differently.* Yes NoI would like my teeth to be WHITER.* Yes NoI snore and/or sleep poorly.* Yes NoAny other concerns:* Yes NoIs there anything we can do to make your appointments more comfortable or convenient for you?* Yes NoPlease remember to advise us of any changes.Date* MM slash DD slash YYYY Signature:*Dr. Signature:All information is kept strictly confidential in accordance with privacy regulations.Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*
