New Patient Registration Form

Thank you for your interest in becoming a patient at Downtown Sleep Dentistry and Oral Surgery. Please fill out the following form to ensure we have all of the required information when you come to our downtown Hamilton dentist office for the first time. If you have any questions or concerns regarding the registration form, please contact us or give us a call at 905-528-8959. 

  • Parent/Legal Responsible Consent Provider

  • Same as above

  • Primary Insurance Information:

    • Name of insured

  • Secondary Insurance Information:

    • Name of insured

  • I understand and agree that I have been given sufficient information to provide my consent to the proposed dental treatment. I am aware of the expected benefits and risks associated with the dentistry, and the possible consequences of alternate procedures, or no treatment at all. This consent allows for other procedures that may become necessary or are advisable in order to complete the planned treatment. I understand that although good results are expected, no guarantees have to be given that the proposed procedure will be curative and/or successful to my exceptions.

    I consent that I have had all the sedation and anaesthesia options explained to me, as well as alternatives to sedation. I have chosen sedation or anaesthesia for my dental work and I am comfortable with the benefits and risks that have been explained to me. Specifically, it has been explained to me that I do not have to have sedation or anaesthesia, but I am choosing to have sedation or anaesthesia. I have had the opportunity to ask questions related to sedation, anaesthesia, as well as my dental work and these have been answered to my satisfaction.

    I have provided a true and accurate medical history to my anaesthesia provider. I have been given a cost estimate as well as preoperative and post operative instructions that include time off of work/school/activities. This consent is valid until revoked in writing.

    Please Sign Below.

  • I consent to the information above and it is true and accurate.

  • Referral Information

  • Referring dentistFacebookGoogleFriend/PatientRadio AdMailerNone