Embracing Health & Beautiful Smiles For The Whole Family!

New Patient Forms

Fill out the forms below and press the submit button after completing each form.
Please fill the form in its entirety.

Please fill out one form per patient. This will help us speed-up the initial check-in process.

Please select the form you wish to complete below.

Dental & Medical History


    Acknowledgement of Dental Cancellation Policy

      Our patients are responsible for providing 48 hours notice for appointment cancellations. If you cancel or no show, we lose two patients, you and the person who could have been treated in that time slot. I acknowledge that without proper notice I may be charged a $125.00 fee per dental provider that is uncollectible by a third party and is my personal responsibility to pay. We do, however, understand that illness and emergencies occur and we do accommodate for those rare instances.

      Our goal is to help you achieve optimum oral health.

      Patient Name

      Dental Records Release

        I, herby authorize to release my dental radiographs and/or records to Grace Family Dental. I also authorize the release of any dental radiographs and /or records for my dependants or for the patients for whom I am guardian

        Please forward digital radiographs and date of complete exam to info@gracefamilydental.ca