Dr. Steven Fremeth

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New Patient Form

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PATIENT REGISTRATION FORM

At your first appointment we will ask you to complete a medical questionnaire. Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. If you have any questions or doubts, please ask the treating dentist or our receptionist. All information is strictly confidential and will remain with this office.

If you prefer you can download our New Patient Form, complete it at home and bring it in with you at your first appointment.

English New Patient Form

French New Patient Form

If you would like someone to contact you to book an appointment please complete the form below and submit it. We will contact you with in 48 business hours.

User Information

Name : Email Address :

Personal Details

Last Name:
First Name:
Date of Birth (dd-mm-yy):

Address

Street:
City:
Province:
Postal Code:

Telephone Numbers

Home Phone:
Work Phone:
Cell:
Spouse Work:
Spouse Cell:

Emergency Contact Details

Contact Name:
Relationship:
Phone:

Responsibility for Account

Name:
Phone:
Workplace (Company):
Phone:
Work Address:

Dental Insurance if held

Insurance Company Name:
Group/Policy #:
Policy Holder:
Certificate/ID #:
Date of Birth (dd-mm-yy):

Are you covered by and Social Assistance Program?

Yes
No

Whom may we thank for referring you?

Name:
Phone: