Deep Dental

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Experience exceptional dental care for a healthier smile at Deep Dental Clinic!
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New patients welcome like family.

Getting started with Deep Dental is as easy as 1, 2, and 3!

1

Comfort meets competence

Whether you seek a new dentist or a second opinion, we make your experience fast and easy. Before booking an appointment, please fill out the new patient info forms shown below (or up to 15 minutes before your scheduled appointment time). Knowing a bit about you and your dental history before we begin enables a smooth, efficient start.

2

Once you’re booked

On your arrival, your dental professional will discuss your situation and requirements verbally with you. Feel free to ask any questions or mention any concerns you have before treatment. Expect to have a pain-free dental exam and full x-rays as part of your first visit.

3

Get Your Registration Done Online (No waiting Request)

We accept most insurance plans, and normally electronically bill direct to insurers, saving you the trouble. We’ll also help you make the most of your plan and answer any coverage questions during your visit.

Medical History Form

    Advancing Dental Care In Our Changing World

    Patient Medical History & Information Form

    Salutation Last Name First Name Preferred Name Date of Birth (DD/MM/YYYY) Sex Address Unit # City/Province Postal Code Telephone number Alt number May we contact you by email? Yes No Email address How did you hear about us? Emergency Contact Phone number

    CASL consent – I consent to communicating with this dental office and receiving important information from this office by email, text messaging or social media. This office is committed to never sending spam email and will always take all reasonable precautions to protect my electronic information. Signature:

    The following information is required to enable us to provide you with the best possible dental care. All information is strictly rivate, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form

    If yes, please explain?

    2. When was your last medical checkup?

    If yes, please explain.

    If yes, please list them.

    a) medications

    b) latex/rubber products

    c) other (e.g. hay fever, seasonal/environmental, foods)

    If yes please explain

    16. Have you had an allergic or bad reaction to any of the following (please check) :

    Other

    17. DO YOU HAVE or HAVE YOU EVER HAD:

    If yes please explain

    If yes please explain

    PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

    Dental History

    Photography

    I consent to photography, filming, and x-rays of my oral and facial structures and the procedure, and their publication for educational and scientific purposes, provided my identity is not revealed. I give up all rights for compensation for publication of these records.

    Patient/Guardian Signature:

    I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical question. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.

    Date Signature

    Consent for Collection, Use and Disclosure of Personal Information.

    I agree that Deep Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed asset out in the Privacy Policy and is in accordance with the Personal Health Information Protection Act,2004.

    Referral Form

    Use this convenient online referral form to provide necessary information for new patients.
    Download the Referral Form

    Consent Form

    Use this form to give Archer Dental permission to access your health care information.
    Download the Consent Form

    X-Ray Release Request

    Download the Form
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