Welcome to Grand Genesis Dental

We’re happy to welcome new patients to our Richmond Hill dental office. Complete your new patient form online before your first visit to help make check-in simple and convenient.

Complete Your New Patient Form

If this is your first visit to Grand Genesis Dental, please complete the form below before your appointment. Your information will help our team prepare for your visit and make check-in easier when you arrive.

New Patient Registration Form

Patient Information

Name

First Name

Last Name

Date of Birth

Phone Number

Email Address

Home Address

Preferred Method of Contact

Phone

Emergency Contact Name

Emergency Contact Phone

Insurance Information

Do you have dental insurance?

Yes

Insurance Company

Policy / Plan Number

Member / Certificate ID

Primary Policy Holder Name

Relationship to Policy Holder

Medical History

Are you in good health?

Yes

Has there been any change in your general health in the past year?

Yes

If yes, please explain

Are you currently taking any medication, non-prescription drugs, or herbal supplements of any kind?

Yes

Please specify medications

Do you have any allergies?

Yes

Please specify allergies

Have you ever been hospitalized for any illness or operation?

Yes

Have you ever had a major illness or serious medical condition?

Yes

If yes, please explain

Are you pregnant or is there a possibility that you may be pregnant?

Yes

Dental History

Have you ever had any complications or problems with previous dental treatment?

Yes

If yes, please explain

Have you had dental X-rays taken within the past year?

Yes

When was your last dental visit?

What is the main reason for your dental visit?

Do you currently smoke or use tobacco products?

Yes

Do you consume alcoholic beverages?

Yes

Does anyone in your immediate family have diabetes, heart disease, or cancer?

Yes

Not Sure

If yes, please specify

Name of Previous Dentist / Dental Office

Previous Dentist Phone Number

Consent & Authorization

Insurance Authorization

I authorize the release of information necessary to process my dental insurance claims and authorize payment of applicable insurance benefits to Grand Genesis Dental.

Patient Acknowledgment

I confirm that the information provided in this form is complete and accurate to the best of my knowledge. I understand that I should inform Grand Genesis Dental of any changes to my health, medications, or personal information.

Consent to Treatment

I consent to the dental examination and treatment considered necessary by the dentist and understand that treatment options, benefits, risks, and alternatives will be discussed with me as appropriate.

Patient / Parent or Guardian Full Name

Electronic Acknowledgment

By submitting this form, I confirm that the name entered above is my own (or that I am the patient’s parent/legal guardian) and that I am submitting this information electronically to Grand Genesis Dental.

Captcha

If you are human, leave this field blank.

Compassionate, modern dental care for patients of all ages in Richmond Hill.

(905) 597-8700

Welcome to Grand Genesis Dental

Complete Your New Patient Form

Patient Information

Insurance Information

Medical History

Dental History

Consent & Authorization

Quick Links

Dental Services

Contact Us