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D.R. Dental Clinic
460 Renforth Drive, Unit 3
Etobicoke, M9C 2N2
W 416-620-1771 F 416-620-1888
drdentalclinics@gmail.com
drdentalclinics.ca

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

Please provide&edsp;&edsp;us the following information for your previous dentist:

Dentist Name:

Dentist Address:

Dentist Phone Number:

Dentist Fax:

Dentist Email:

Authourization

I hereby authorize the release of my / my family’s Dental radiographs and any dental records to our office. In addition please note date of last Recall/Exam and any additional information that would be beneficial to my dental care.

Please forward at your earliest convenience.

Date of Recall or New Patient Exam:____________________________

Please provide a copy of clinical notes.

Signature