Mon – Fri: 9:00 AM – 6:00 PM · Flexible scheduling available!905-825-2344

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Welcome

New Patient Form

Please complete this form before your first visit. Your information helps us provide the safest, most personalised care possible.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Phone Number *

Email Address

Street Address

City

Postal Code

Emergency Contact

Full Name

Relationship

Phone Number

Dental Insurance

Insurance Provider

Policy Number

Member ID

Policy Holder Name

Dental History

Date of Last Dental Visit

Previous Dentist / Practice

Chief Dental Concern

Medical History

Please check all conditions that apply:

Heart DiseaseHigh Blood PressureDiabetesAsthmaEpilepsyThyroid DisorderKidney DiseaseLiver DiseaseHIV/AIDSCancerOsteoporosisArthritisBlood DisorderStrokeNone of the above

Current Medications

Known Allergies

Do you smoke or use tobacco?

Are you pregnant or nursing?

Do you experience dental anxiety?

Additional Notes

Anything else you'd like us to know?

SMS Notifications

Mobile Number for SMS

Enter a Canadian mobile number if you'd like to receive SMS reminders from our office.

I consent to receive SMS text messages from Ocean Dental Care at the mobile number provided above. Messages may include appointment reminders, confirmations, and office updates. Message and data rates may apply. Reply STOP at any time to opt out.

Signature

By signing below, you confirm that the information provided is accurate and complete to the best of your knowledge, and that you consent to the collection and use of your personal information as described in our Privacy Policy.

Patient / Guardian Signature *

Sign here

Draw your signature above using your mouse or finger.

Date: July 31, 2026

I consent to Ocean Dental Care collecting and using my personal and medical information for the purpose of providing dental care, as described in the Privacy Policy. I understand this information will be kept confidential and I may withdraw consent at any time by contacting the office.

Your information is kept strictly confidential and used only to provide your dental care.

Contact Us

905-825-2344

Mon – Fri: 9:00 AM – 6:00 PM

204-1131 Nottinghill Gate
Oakville, ON L6M 1K5

What to Bring

·Health card (OHIP)
·Insurance card & details
·List of current medications
·Any dental X-rays if available

Providing compassionate, high-quality dental care for the whole family in a warm, welcoming environment.

Quick Links

Home Services About Us Request Appointment Patient Forms Contact

Office Hours

Mon – Fri: 9:00 AM – 6:00 PMWeekends: Closed

Contact Us

905-825-2344

Fax: 905-825-8350

[email protected]

204-1131 Nottinghill Gate
Oakville, ON L6M 1K5