Highland Creek Dental - New Patient Registration

PERSONAL INFORMATION

* Instructions:

The fields marked by star (*), are required and must be filled out.
If you have any question or need clarification regarding the form, please do not hesitate to call our office at 416-282-5562.
Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.

First Name

Last Name

Preferred

Title:

Dr.

Mr.

Mrs.

Ms

Other

If "Other" type here

Date of Birth

MM

/

DD

/

YYYY

Address

City

Postal Code

Cell Phone

Home Phone

Occupation

Work Phone

Email

I consent to receive appointment notifications and newsletters

Which one of below methods is the quickest and most reliable way to get in touch with you?

Home Phone

Work Phone

Cell Phone

Text Message

E‐mail

Other

If "Other" type here

Notes (specific time of the day or any consideration):

EMERGENCY INFO

Emergency Contact - Full Name:

Relationship :

Emergency Cell Phone :

Emergency Home Phone :

Notes (specific contact instructions or preferences):

Family Physician - Full Name:

Office Phone:

Specialist - For:

Full Name:

Office Phone:

VISIT INFORMATION

How can we help you?

Comprehensive Exam

Pain Relief/ Emergency

Dental Hygiene/Cleaning

Other

If "Other" type here

How did you hear about us?

Referral: Name of Referral:

Social Media :

Facebook

Instagram

Google

Website

Signage

Flyers

Newspaper

Magazine

Other

If "Other" type here

DENTAL INSURANCE INFORMATION

Primary Insurance:

Insured Name:

First:

Last:

Insured Date of Birth:

MM

/

DD

/

YYYY

Insured Employer:

Insurance Company:

Plan or Group :

Certificate/Member ID #:

Secondary Insurance (if available):

Insured Name:

First:

Last:

Insured Date of Birth:

MM

/

DD

/

YYYY

Insured Employer:

Insurance Company:

Plan or Group :

Certificate/Member ID #:

Relationship to Insured:

Insured Cell Phone:

MEDICAL HISTORY AND INFORMATION

When was your last Dental visit?

MM

/

DD

/

YYYY

When was your last Medical check‐up?

MM

/

DD

/

YYYY

Do you have tendency to bruise easily or bleed for a prolonged period of time?

Yes

No

Have you ever had or are receiving Chemo or Radiation Therapy?

Yes

No

Do you require any Medications or Antibiotics before Dental Treatment?

Yes

No

If yes, please provide details:

Are you currently being treated for any Medical conditions? Are you currently being required to self-isolate?

Yes

No

If yes, please provide details:

Are you taking any Medications (including blood thinners) or Non-Prescription Drugs?

Yes

No

If yes, please provide details:

Has there been any changes in your general health recently? Have you gained or lost excessive weight?

Yes

No

If yes, please provide details:

Have you ever been seriously ill, hospitalized or had any major surgery?

Yes

No

If yes, please provide details:

Have you ever had a peculiar or adverse reaction to any Medication, Injection or Anesthesia?

Yes

No

If yes, please provide details:

Do you have allergies or sensitivities to any Food or Material (including Latex)?

Yes

No

If yes, please list all:

Do you have or ever had the following :*

Chest Pain/Angina

Shortness of Breath

Nausea

Fainted

None

Do you have or ever had the following :*

AIDS/ HIV Positive

Hepatitis

Tuberculosis

Asthma

Heart Attack/Condition

High Blood Pressure

Heart Murmur

Pacemaker

Mitral Valve Prolapse

Rheumatic Fever

Sinusitis

Bronchitis

Stomach Ulcer

Liver Disease

Kidney Disease

Diabetes

Psychiatric disorders

Drug/Alcohol dependency

Smoke/Vape heavily

Arthritis

Do you have or ever had the following :*

Teeth Grinding/Clenching

Pain/Tenderness in Jaw

Bleeding Gum

Bad Breath

None

For Woman Only :*

Take birth control pills

Breast Feeding

Special Care

Pregnant

Pregnancy Due date:

MM

/

DD

/

YYYY

PATIENT CONSENT * (Required)

I understand that all my information will be kept strictly confidential in accordance with privacy regulations; and, I authorize release as is necessary to provide proper and safe services.

I consent the Dentist and auxiliary staff to perform necessary examination, diagnostic procedures and treatment, as required, to achieve the proper level of dental care.

I acknowledge that I would be financially responsible for the Dental services provided regardless of insurance coverage; and, I understand payments are due when services are rendered.

I understand that the appointment time given to me is reserved for me only; and as a courtesy to time anddedication of Dentist and auxiliary staff, it is my responsibility to inform the office if I need to change or cancelat least 2‐business‐day before my appointment. I acknowledge that if I fail to do so, I would be responsible topay no‐show or short‐notice cancelation fee with no exception other than for extreme emergencies.

I certify that I have read, understood and accurately completed this form to the best of my knowledge and havenot knowingly omitted any information. I also acknowledge that it is my full responsibility to inform the office ofany changes prior to my upcoming appointment and fill the "Patient Update Form" once in the office.

Name

Date

03

/

29

/

2025

Signature

* Notes:

Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.
If you’ve not filled any required field, form will not be submitted and required fields will be shown in red to be filled.
If you’ve filled all required fields, a confirmation message will be shown; and, a copy of the form will be sent to your email as well.

Verification

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