Patient Registration Form

Welcome to Bloor Dental Clinic. We look forward to getting to know you, your family and friends and caring for your dental health, with the goals of high quality and gentle dentistry in mind. We treat all of our patients in the same manner as we would treat our families and ourselves. We will present you with your diagnosis and treatment options, honestly and openly, to help you make confident choices. We are proud our self and friendly environment, dependable and punctual services

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  • I affirm that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform the office of any changes in my medical status.
  • I acknowledge that my dental benefits are my responsibility I understand that I am responsible for payment of services rendered for my dependents and myself. Payment is due on the day of service rendered unless otherwise financially arranged. a fee of $45.00 is changed per NSF cheque.
  • My appointments are considered confirmed when scheduled. Bloor Dental Clinic requires a notice of 2 business days for any changes to my reserved appointment. A fee of $50.00 per appointment is changed for no-show, or short notice cancellation.
  • I have reviewed the information that explains how Bloor Dental Clinic will use my personal information. and the steps Bloor Dental Clinic will take to protect my information. I agree that Bloor Dental Clinic can collect, use and disclose personal information about my dependents & myself as set out in the information about the privacy policies. I can ask to see these policies at any time.
  • I give consent to that dental staff to provide the necessary diagnosis and treatment, and authorize the release of my information and my dependents to information my dental insurance company/plan administrator for Electronic Dental Insurance (EDI) submission.

we are pleased to answer any questions you may have or receive your feedback thank you for joining our dental family at Bloor Dental Clinic