Returning Patient RETURNING PATIENT FORMBOOK AN APPOINTMENT Patient InformationName* First Last Email* Phone*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code If available, please confirm this date and time to visit Start Fresh Dental Hygiene.* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM Medical Health HistoryAny change in your general health in the past year? No Yes If Yes, please specify here:Are you presently taking any Prescription or NON Prescription drugs? No Yes If Yes, please specify here:(Include herbal remedies)Additional InfoPlease add anything else you would like us to know about:Patient DeclarationI, the undersigned, certify that I have provided an accurate and complete personal, medical history and have not knowingly omitted any information. Should there be any changes in either my health or any other information I have provided, I will advise this dental hygiene office. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy. I understand that responsibility for payment of the dental hygiene services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. *The Submit button will appear after certify that the information above is accurate. Yes, I certify that the information above is true.* Subscribe to mailing listI would like to receive promotions and special offers from your company. Yes, add me to the mailing list. EmailThis field is for validation purposes and should be left unchanged.
