Forms Online Patient Registration Online Patient Registration Who are you filling this form out for? * Myself Someone else Patient is myself What is your full name? * Do you have insurance? Yes No Insurance Companies Option 1 What is your sex? * Female Male What is your date of birth? * Where will the dental service be provided? * Care facilityYour homeHospitalReserveOther Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Reserve Ebb-and-Flow Do you have a treaty card? * Yes No Please enter the Treaty card number * Please list any allergies you have: Please list any medications you are currently taking: Are you currently pregnant or is there a chance you could be? * Yes No Patient is someone else What is the patient's full name? * Does the patient have insurance? Yes No Insurance Companies Option 1 What is the patient's sex? * Female Male What is the patient's date of birth? * Where will the dental service be provided? * Care facilityYour homeHospitalReserveOther Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Reserve Ebb-and-Flow Does the patient have a treaty card? * Yes No Please enter the Treaty card number * Please list any allergies the patient has: Please list any medications the patient is currently taking: Is the patient currently pregnant or is there a chance they could be? * Yes No What is the full name of the patient's next of kin? * Please provide the email address to send the account: * example@example.com Confirm Please provide the email address to send the account: * Please provide the name, contact number and address of the person who holds financial responsibility (FPOA, State Trustees, Self etc) * I give permission for the following treatment/s: * I give permission on behalf of the patient for the following treatment/s: * Please upload a photo of insurance card (treaty, social assistance, or insurance company) Drop a file here or click to upload Choose File Maximum file size: 268.44MB Captcha Submit If you are human, leave this field blank. Δ Better Dental Care is Our Mission Contact Us Today To Learn More About How We Can Help You Make an Appointment