Northern Horizon Dental
Like Northern Horizon Dental on FacebookSubscribe to Northern Horizon Dental on YouTubeFollow Northern Horizon Dental on Twitter+1 Northern Horizon Dental on Google Plus
Listen to our new ad!
Pause

Perfecting smiles one smile at a time in Barrie & Innisfil

632 Yonge Street

Barrie, ON L4N 4E7

(705) 719-7645

2081 Jans Blvd

Innisfil, ON L9S 4Y8

(705) 431-9111

Northern Horizon Dental
Like Northern Horizon Dental on FacebookSubscribe to Northern Horizon Dental on YouTubeFollow Northern Horizon Dental on Twitter+1 Northern Horizon Dental on Google Plus
Listen to our new ad!
Pause

Perfecting smiles one smile at a time in Barrie & Innisfil

632 Yonge Street

Barrie, ON L4N 4E7

(705) 719-7645

2081 Jans Blvd

Innisfil, ON L9S 4Y8

(705) 431-9111


New Patient Registration

Patient Information

Name*: Date:
Address*: City*: Postal Code*:
Home Phone: Work Phone:
Cell Phone: Email*:

Preferred contact: Home PhoneWork PhoneCell PhoneEmail

Date of Birth: Age: Gender: Marital Status: Name of school: Grade:

In case of an emergency, we may contact:

Phone: Relationship to Patient:

Responsible Party

Complete If Information Is Different Then Above

Name: Relationship to Patient:
Address: City: Postal Code:
Date of Birth: Employer:

Is this person currently a patient of our office? YesNo

Insurance Information

Primary Insurance

Name of policy holder: Date of Birth:
Employer:
Insurance company:
Group/Plan/Policy#: Certificate/ID #:

DO YOU HAVE ADDITIONAL INSURANCE? YesNo If YES, complete the following:

Secondary Insurance

Name of policy holder: Date of Birth:
Employer:
Insurance company:
Group/Plan/Policy#: Certificate/ID #:

Click Here To Download Form in PDF Format

0
Connecting
Please wait...
Send a message

Sorry! We aren't around right now. Leave a message and we'll get back to you, asap.

Your name
* Email
* Describe your issue
Login now

Questions? We're here. Send us a message!

Your name
* Email
* Describe your issue
We're online!
Feedback

Help us help you better! Feel free to leave us any additional feedback.

How do you rate our support?