Book Now

New Patient Form

"*" indicates required fields

New Patient

Name*
Date of Birth*
Address*
Dental History

Date of last dental visit
Are you presently on dental plan?*
Emergency Contact

Emergency Contact Name*
Medical History

Have you been examined and/or treated by physician within the last year?*
Have you ever had any major operation?*
Have you ever had an unusual reaction to any drugs such as Codeine, Aspirin, Penicillin, Sulfa or Dental Anaesthetic?*
Are you taking any medication?*
Do you take any non prescription drugs?*
Do you have Artificial joint?*
Have you ever had Chemotherapy?*
Are you on disability?*
Are you pregnant?*
Do you smoke?*
Do you have or have you had any of the following?*
Treatment Authorization and Release*

Copyright © 2025 - All Rights Reserved - Glen Dental Centre - Privacy Policy
Website by ElementIQ
chevron-right