New Patient Form

Full Name *

First

Last

Gender *

Residential Address *

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth *//

(Day / Month / Year)

Contact Mobile Number *

(Please do not include spaces)

Email Address *

Emergency Contact: Name

Emergency Contact: Relationship to Patient *

Emergency Contact: Contact Number *

In a few words, please inform us what brings you to Floss Dental... *

Do you suffer from any of the following conditions? (Please select any that apply) *

Are you on any medication (including blood thinners), or have any other medical conditions? If so, please specify... *

Do you currently have Private Health Insurance? *

Name of other Health Fund *

Please advise if you are still subject to any Dental Waiting Periods *

What is your preferred method of settling your Out-of-Pocket GAP? *

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