Screening Registration Card

Fields denoted by an asterisk (*) are required

Name Name First Last
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Gender

Gender Male Female
Birth Date Birth Date / MM / DD YYYY
Appointment Information
Have you ever applied to become or have you ever been a patient of U.W.O. Schulich Dentistry before?

Have you ever applied to become or have you ever been a patient of U.W.O. Schulich Dentistry before? Yes No
Please indicate the year: (e.g. 2004)
Were you referred by your Dentist?

Were you referred by your Dentist? Yes No
Dentist's Name:
Referring Dentist's Phone Referring Dentist's Phone - ### - ### ####
for the treatment of
Date of last dental appointment Date of last dental appointment / MM / DD YYYY
I would like to be treated for (check the appropriate boxes):

I would like to be treated for (check the appropriate boxes): Fillings Broken teeth Aching teeth Sore and/or bleeding gums Crowns Implants Fixed bridges to replace missing teeth Removable partial dentures to replace many missing teeth Complete Dentures
You have indicated you would like complete dentures. Please complete the two (2) fields below:
How many teeth do you currently have?
Extractions Required:

Extractions Required: Yes No