Returning Patient RETURNING PATIENT FORM BOOK AN APPOINTMENT EmailThis field is for validation purposes and should be left unchanged.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.
