PATIENT REGISTRATION

The data on this confidential questionnaire is essential in our efforts to provide you with the best professional care. We appreciate your co-operation in completing it. Our office is in compliance with the National Personal Information Protection and Electronic Document Act.

Patient Information
Fields are mendatory

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Medical Information

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# Medication Dose Frequency
1
2
3

For Women Only

Yes No
Yes No

                 



A thorough examination and consultation is a crucial and necessary service prior to the initiation of endodontic treatment. A fee is assessed for this treatment in accordance with the fee guide of the Ontario Dental Association wheter or not endodontic treatment is performed. Payment of this fee is expected at this examination appointment.

I acknowledge full responsibility for the payment of such services formy endodontic treatment and agree to pay for them in full when the services have been rendered, unless other specific arrangements are made with the secretary.

I also understand that it will be necesssary for me to return to my family dentist for the permanent restoration following the endodontic treatment.