Welcome to our Practice!

In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

NOTE: Fields marked with an asterisk (*) are required.

PATIENT INFORMATION

Title:

Patient Name:*

Date of Birth:*

Sex:

Address:*

Employer:
Occupation:
CONTACT INFORMATION
Home Phone
Work Phone
Mobile Phone
Email Address
Emergency Contact:*
Phone Number:*
Spouse:
Phone Number:
Family Doctor:
Phone Number:
In the event that we must contact you for scheduling changes, etc, please indicate the BEST PHONE NUMBER during business hours to phone you:
Phone Number:
How did you hear about us?
Internet
Patient Referral
Website
Yellow Pages
Mailer
Other
If you were referred, whom may we thank for their trust in us?
Referral Name:

INSURANCE INFORMATION
Do you have Dental Insurance?* Yes   |   No

If yes, please refer to Dental Insurance Electronic Processing Form

CONSENT

  I hereby authorize Dr. Justin Lee Dentistry Professional Corporation to take the necessary X-rays, study models, photographs or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my/the patient's dental needs. I also authorize Dr. Justin Lee Dentistry Professional Corporation to perform all forms of treatment, medication and therapy that is agreed to be necessary or advisable. I also understand the use of anesthetic agents embodies a certain risk.

I fully understand that it is my financial responsibility for all dental treatment provided, regardless of insurance coverage, and understand that complete payment will be made after each treatment.

We accept Cash, Debit, Visa and MasterCard. Appointment times are reserved for you and we require 48 hours notice (2 business days) notice if you are required to change an appointment. A fee may be charged for cancelled or missed appointments without sufficient notice.


Patient (or Guardian) Initials:

Cornwall Dental Arts

806 Pitt Street
Cornwall, ON K6J 3S2

Monday   8:00am 5:00pm
Tuesday   8:00am 7:00pm
Wednesday   8:00am 5:00pm
Thursday   8:00am 5:00pm
Friday   8:00am 4:00pm
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Professional Affiliates

American Academy of Cosmetic Dentistry
Academy of General Dentistry
Invisalign
Kois Center: Advancing Dentistry Through Science
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