New Patient Form

Download our new patient form if you'd prefer to bring it in.

01Patient Information

Preferred Name

Please enter a valid preferred name.

Last Name

Please enter a valid last name.

Date of Birth

Please enter a valid date of birth.

Telephone Number

Please enter a valid telephone number.

Home Address

Please enter a valid home address.

Employment

Employer

Occupation

Emergency Contact

Emergency Contact Name

Please enter a valid emergency contact name.

Emergency Contact Phone

Please enter a valid emergency contact phone.

Relationship

02Medical References

Dentist Information

General Dentist Name

General Dentist Telephone

Family Physician Information

Family Physician Name

Family Physician Telephone

Pharmacy Information

Pharmacy

Pharmacy Telephone

Do you have insurance coverage?

Yes

If so, insurance provider/policy:

* I understand that the answers to these questions are necessary to provide me with the best possible care and favourable outcome. I have answered all questions truthfully and to the best of my knowledge. I consent to Fourth Ave Endodontics obtaining any other information from other practitioners who are currently or have treated me in the past that will be necessary in providing proper care.

* I understand that the total payment of dental services is my responsibility, and not that of the insurance company. Payment is due when services are rendered.

Address

Suite 237 - 1338 Fourth Ave, St. Catharines

Phone

Tel: (289) 362 - 2980

Fax: (289) 362 - 3382

E-mail

info@fourthaveendodontics.com

Hours

Monday - Friday: 8am - 5pm

Payment Options

Your consultation appointment will provide you with a predetermination outlining the costs of your upcoming treatment. Payment will be due at the time service is rendered. We accept Visa, Mastercard, Debit, American Express or cash payments. If you have insurance coverage, we can assist you in submitting your claim electronically or provide you with the forms necessary for you to submit independently.

New Patient Form

New Patient Form

01Patient Information

Employment

Emergency Contact

02Medical References

Dentist Information

Family Physician Information

Pharmacy Information

Do you have insurance coverage?

03Dental Information

Personal Health

Would you consider yourself to be in good health?

Do you smoke?

Any changes in health in the last year?

Have you had any allergic or adverse reactions to the following?

Do you have, or have had, any of the following conditions (please select all that apply):

Any medical conditions not listed:

Any medical conditions that run in your family?

Additional comments

Have you ever been hospitalized?

WOMEN:

Are you pregnant?

Are you breastfeeding?

Approximate Due Date

Are you taking any vitamins or herbal supplements?

Recreational Drug Use

Approximate Weekly Alcohol Intake

Have you ever had root canal/endodontic therapy?

If yes:

How would you rate your previous experience?

Have you ever been recommended antibiotic coverage prior to surgery or dental procedures?

Have you ever had abnormal bruising/bleeding associated with a dental procedure?

Have you ever had an adverse reaction to dental freezing/local anesthetic?

Where would you rate your level of nervousness about dental treatment?

Current Medications

Address

Phone

E-mail

Hours

Payment Options

Book a consultation with us today.