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      • Ridge Modification
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  • Home
  • About
    • About Boeriu Implant Dentistry
    • Meet Dr Boeriu
    • Review Us
  • Dental Procedures
    • Preventive Periodontal Treatment
      • Complete Dental Examination
      • Dental x-Rays
      • Digital x-Rays
      • Fluoride Treatment
      • Home Care
      • Oral Hygiene Aids
      • Sealants
    • Dental Prophylaxis (Professional Dental Cleaning)
    • Periodontal Treatment
      • Antibiotic Treatment
      • Bone Grafting for Periodontal Disease
      • Bruxism
      • Crown Lengthening
      • Gum Grafting
      • Gum Recession
      • Oral Cancer Exam
      • Periodontal Scaling & Root Planing
      • Pocket Irrigation
      • Pocket Reduction Surgery
      • Restorative Procedures
      • Ridge Modification
      • Sinus Augmentation
      • Soft Tissue Grafting
    • Periodontal Disease
      • What Is Periodontal Gum Disease
      • Diagnosis
      • Treatment
      • Maintenance
      • Causes Of Periodontal Disease
      • Types Of Periodontal Disease
      • Signs Symptoms Of Periodontal Disease
      • Mouth Body Connection
      • Periodontal Disease And Diabetes
      • Periodontal Disease Heart Disease And Stroke
      • Periodontal Disease And Pregnancy
      • Periodontal Disease And Osteoporosis
      • Periodontal Disease And Respiratory Disease
    • Restorations
      • Amalgam Fillings
      • Crowns Caps
      • Dentures Partial Dentures
      • Fixed Bridges
      • Inlay Restorations
      • Onlay Restorations
    • Endodontics
      • Cracked Tooth
      • Root Amputation
      • Root Canal Retreatment
      • Root Canal Therapy
  • Dental Implants
    • Single Tooth Replacement
    • Multiple Teeth Replacement
    • Full Arch Implant Retained Devices
    • Dental Implants Faqs
  • Cosmetic Dentistry
    • Porcelain Crowns
    • Porcelain Inlays
    • Porcelain Veneers
    • Porcelain Fixed Bridges
    • Porcelain Onlays
    • Teeth Whitening
    • Composite Fillings
  • Patient Info
    • Initial Dentist Appointment
    • Patient Forms
      • New Patient Form
      • Medical History Update
      • 5 Year Medical History Update
      • Covid-19 Patient Screening Form
      • COVID-19 Pandemic Dental Risk Consent
    • Payment Options
    • Dental Warranty
    • FAQs
  • Blog
    • News
  • Service Areas
    • Kitchener Ontario
      • Alpine Ontario
      • Bridgeport Ontario
      • Brigadoon Ontario
      • Centreville Ontario
      • Country Hills West Ontario
      • View All Areas
  • Book An Appointment
New Patient Form

New Patient Form

Sorin Boeriu DDS

866 Frederick Street
Kitchener, ON N2B 2B8 Canada
Phone: (519) 578-7830

DD slash MM slash YYYY
Patient Name(Required)
Date of Birth(Required)

Gender

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
What pronouns do you prefer that we use when referring to you? (check all that apply)

Contact Information

Address(Required)
Family Physician(Required)
In Case of Emergency, We should notify:(Required)

Payment Information

Party Responsible for Payment

Insurance Information

*Please note, patient is responsible with providing us a copy of their insurance card(s).*

Primary

Name of Insured
Insured's Birth Date

Secondary

Name of Insured
Insured's Birth Date

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic
Aspirin/Advil
Codeine
Latex
Local Anesthetics/Novocain
Other

Have you ever had any of the following? Please check those that apply:

Neural
Cardiovascular
Pulmonary
Infectious
Immune
Neoplastic
Digestive
Inflammatory
Other
If you had any surgeries please specify the surgery date and information.
Due Date
When did you quit?
Whom may we thank for referring you to our practice ?(Required)

Consent for Services & Office Agreement

* I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.

*I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).

*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.

*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.

*My dental insurance plan is a contract between myself and the organization providing me with the coverage. It is my responsibility to ensure that the treatment I request is covered. However, Sorin Boeriu DDS will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Sorin Boeriu DDS has NO knowledge of what is covered by my insurance plan. If I have a booklet, Sorin Boeriu DDS will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Sorin Boeriu DDS will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.

* Sorin Boeriu DDS also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.

* Sorin Boeriu DDS will always make every attempt to see emergency cases promptly.

* Sorin Boeriu DDS will accept Visa, MasterCard, debit, cash or cheque.

* Sorin Boeriu DDS will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent for Collection, Use and Disclosure of Personal Information

* I agree that Sorin Boeriu DDS has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.
Consent(Required)
DD slash MM slash YYYY

About Sorin Boeriu DDS

At Boeriu Implant Dentistry, your Kitchener Dentist we are devoted to restoring and enhancing the natural beauty of your smile using conservative and modern procedures that can result in beautiful, long lasting smiles!

5 star

Kitchener Dentist Office

Sorin Boeriu DDS
866 Frederick Street
Kitchener, ON N2B 2B8
Canada
(519) 578-7830
[email protected]

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