New Patient Form

GENERAL INFORMATION

First Name

Last Name

Email Address

Phone Number

Date of Birth

Gender

Home Address

City/Town

Postal Code

Referring Dentist (if applicable)

CONSENT TO DENTAL FEES

Oral Radiology Toronto does not accept assignment of dental insurance benefits (direct billing). This means that you, the patient, are responsible for payment at the time dental treatment is rendered. Our office will help you process any insurance claims and you will be reimbursed by your dental insurance directly. We accept debit card, Master card and Visa. Please speak us if you have any further questions or concerns.

By submitting this form, I consent to Oral Radiology Toronto's terms of payment.

CONSENT TO COLLECTION OF PERSONAL HEALTH INFORMATION

I agree that Oral Radiology Toronto can collect, use and disclose my personal health information as set out in the PRIVACY STATEMENT.

By submitting this form, I consent to Oral Radiology Toronto's privacy statement.

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF THE KNOWLEDGE

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