Patient Information Form - Village Square Dental Centre

~---~---------
Welcome to our Office
To help us meet all of your heaIthcare needs, please fill out this form completely. If you have any questions or need assistance,
please ask us and we will be happy to help.
Patient Information (Confidential)
Name
_ Date ofBirth
Admess
_ City
_
Province
_
•
Postal Code
Home Phone
Cell Phone
Health Card Number:
_
E-mail
_
Driver's License
If Student, Name of Un iversityl College
_
City
Patient's Employer
_
Work Phone
_
Person to contact in case of emergency
Phone
_
Nearest Relative not living with you
Phone
_
Information ifpatient is a minor
Mother's Name
Address (if different)
City
_
PosmICode
Father's Name
HomePhone
_
Address (if different)
City
_
PosmICode
Insurance Information
OYes
S.LN.
Insurance Company
Relationship
_
Name ofEmployer
_
Policy
How much is your deductible
Do You Have Any Additional
_
ONo
Name of Insured
Birthdate
HomePhone
LD. #
Annual Max
Insurance?
DYes
ONo
_
If yes, complete the following
Name of Insured
Birthdate
Recare cycle
_
Relationship
S.LN.
_
Name ofEmployer
Insurance Company
Policy
How much is your deductible
Annual Max
_
LD. #
Recare cycle.
_
_
Person Responsible for Account if not residing at same residellce
Admess
City
Home Phone
Cell
For your convenience,
Work Phone
Email
_
we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
o Cash
Whom may we thank forreferring
_
o Cheque
o Visa
o MasterCard
oAmex
you?
o Debit Card
_
Thank you for selecting us.