Patient Registration Form

Welcome to Cedarbrae Dental. We look forward to getting to know you, your family and friends and caring for your dental health, with the goals of high quality and gentle dentistry in mind. We treat all of our patients in the same manner as we would treat our families and ourselves. We will present you with your diagnosis and treatment options, honestly and openly, to help you make confident choices. We are proud our self and friendly environment, dependable and punctual services

About the patient



































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If so, please give your insurance information to the front desk.

Dental History



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Doy you have any of the following?


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Medical History











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Medical History Cont.


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Abnormal bleedingAbnormal bruisingBlood transfusionBlood disorderHemophiliaLiver diseaseJaundiceHepatitis ABCSickle cell anemiaAnemiaProstate problemsPre medication with antibiotics for dental treatmentHead/neck injuriesHeadaches/migraines
Sinus problemsGlaucoma/CataractArtificial jointsSeizures/EpilepsyArthritis/RheumatismLupasOrgan transplantColitis/UlcersEver hospitalizedAlcohol/drug abuseSteroid therapyCancerRadiation treatmentChemotherapy
Venereal diseaseHerpesImmune problemsHIV/AIDSPsychological problemsMalignant hyperthermimTuberculosis (TB)Persistent coughEmphysemaAsthmaLung problemShortness of breathThyroid problems
Kidney problemsDiabetesStrokeHigh/low blood pressureHigh cholesterolCongenital heart beatHeart murmurHeart surgeryHeart attack/ AnginaPacemakerSwollen ankles, feet or hands






Women Only:


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AspirinBarbituratesCodeineAnaesthesiaErythromycinPenicillinClindamycinSulfa drugsTetracyclineInjectionsJewelry/metalsLatex



  • I affirm that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform the office of any changes in my medical status.
  • I acknowledge that my dental benefits are my responsibility I understand that I am responsible for payment of services rendered for my dependents and myself. Payment is due on the day of service rendered unless otherwise financially arranged. a fee of $45.00 is changed per NSF cheque.
  • My appointments are considered confirmed when scheduled. Cedarbrae Dental requires a notice of 2 business days for any changes to my reserved appointment. A fee of $50.00 per appointment is changed for no-show, or short notice cancellation.
  • I have reviewed the information that explains how Cedarbrae Dental will use my personal information. and the steps Cedarbrae Dental will take to protect my information. I agree that Cedarbrae Dental can collect, use and disclose personal information about my dependents & myself as set out in the information about the privacy policies. I can ask to see these policies at any time.
  • I give consent to that dental staff to provide the necessary diagnosis and treatment, and authorize the release of my information and my dependents to information my dental insurance company/plan administrator for Electronic Dental Insurance (EDI) submission.

we are pleased to answer any questions you may have or receive your feedback thank you for joining our dental family at Cedarbrae Dental