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Medical History Form

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(5642847) New Patient Form

PERSONAL INFORMATION *

* Instructions:

  1. The fields marked by star (*), are required and must be filled out.
  2. If you have any question or need clarification regarding the form, please do not hesitate to call our office at 416-221-6621.
  3. Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.

EMERGENCY INFO

PATIENT INFORMATION

DENTAL INSURANCE INFORMATION

Primary Insurance

Secondary Insurance (if available):

MEDICAL HISTORY AND INFORMATION

PATIENT CONSENT * (Required)

Patient/Parent/Guardian Signature *
 

Please sign using your finger, mouse, or stylus.

* Notes:

  1. Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.
  2. If you’ve not filled any required field, form will not be submitted and required fields will be shown in red to be filled.
  3. If you’ve filled all required fields, a confirmation message will show.

Why Choose Us?

New Patients
& Referrals Always
Welcome

416-221-6621

Fill It Out Online or
Bring A Hard Copy of
Medical History Form
On Your Visit

Medical History

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Book Your Dental Appointment Today!

Remember to bring proof of eligibility for your appointment
and everything you need for your visit..
We look forward to seeing you.

Exterior of Northtown Dental at 5075 Yonge Street North York, accepting CDCP patients near Sheppard-Yonge Station

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VISIT US


Northtown Dental
5075 Yonge Street, Suite 102
North York, Ontario
M2N 6C6

HOURS OF OPERATION


Mondays: 8:00 am-4:00 pm
Tuesday: 9:00 am - 6:00 pm
Wednesday: By Appointment
Thursday: 9:30 am - 6:00 pm
Friday: Closed
Saturday: 8:00 am - 2:00 pm (Alternating)
Sunday: Closed