What information is required on the new patient registration form?

The form collects patient contact information, date of birth, emergency contact details, medical history, medication and allergy information, dental insurance information, and required privacy, financial policy, treatment consent, and signature details.

Does the registration form ask about dental insurance?

Yes. The Smile Care Studio registration form includes sections for dental insurance coverage, insurance company, policy holder information, group or plan number, and ID or certificate number.

Where is Smile Care Studio located?

Smile Care Studio is located at 1480 Walsh St W, Thunder Bay, Ontario, Canada.

How can I contact Smile Care Studio?

You can contact Smile Care Studio by phone at +1 (873) 688-5426 or complete the online new patient registration and appointment request form.

New Patient Registration Form | Smile Care Studio Thunder Bay

Q: Who should complete the Smile Care Studio new patient registration form?

New patients visiting Smile Care Studio in Thunder Bay, Ontario, should complete the registration form before their appointment so the studio can collect important contact, medical, insurance, and consent information.

New Patient Registration Form in Thunder Bay

New Patient Registration Form

Complete the Smile Care Studio new patient registration form for personalized dental hygiene care in Thunder Bay, Ontario. Register today.

Section 1

Patient Contact Information

Full Legal Name *

Date of Birth *

Gender Identity *

Primary Phone Number *

Email Address *

Current Street Address *

Emergency Contact Name *

Emergency Contact Phone Number *

Section 2

Medical History Questionnaire

Section 3

Dental Insurance Policy Information

Policy 1

Do you have dental insurance coverage?

Insurance Company Name

Policy Holder Name

Policy Holder Date of Birth

Group/Plan Number

ID/Certificate Number

Policy 2

Do you have dental insurance coverage?

Insurance Company Name

Policy Holder Name

Policy Holder Date of Birth

Group/Plan Number

ID/Certificate Number

Section 4

Privacy & Financial Policy Acknowledgement

Notice of Privacy Practices *

Financial Policy *

Consent to Treatment *

Signature of Patient/Guardian *

Date of Signature *