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NEW PATIENT FORM

Welcome to Parkside Drive Dental! Please fill out this form with all current medical information.

"*" indicates required fields

Patient Information

Name:*
Preferred Name
Preferred Pronouns
D.O.B(mm/dd/yyyy)*

Family Doctor/Emergency Contact

Family Physician:
Emergency Contact Name:*

Dental Insurance (Primary Coverage)

Dental Insurance (Secondary Coverage)

Medical History

Please list the medications you are currently taking: (Non-prescription drugs or herbal supplements included)

Do you have, or have ever had any of the following? Please check

Personal Health Information Act

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the new collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance. Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.

Patient Consent

I have reviewed the above information that explains how my office will use my personal health information, and the steps your office is taking to protect my information. I agree that Parkside Drive Dental can collect, use and disclose my personal health information as set out above in the office’s privacy policies. To the best of my knowledge, the above information is correct:

Print Name:*
MM slash DD slash YYYY
(Parent/Guardian if patient is under 18)

OUR LOCATION

Parkside Drive Dental is located in South of the Conestoga Parkway in the plaza on the northeast corner of Weber St. N and Parkside Dr.

Associations

550 Parkside Drive Unit A5 Waterloo • ON N2L 5V4 Canada •  519-885-0810 

PARKSIDE DRIVE DENTAL 2022 | PRIVACY POLICY •   SITE DEVELOPED BY 151 DIGITAL