New Patient Form

Anxious about visiting the dental clinics? Drop your worries aside as Tooth Buds Dentistry is committed to providing excellent dental services with a dental professional’s gentle touch.

Relax! You are at the right place!

We understand the perceptions and your hesitations while visiting the dental clinic. Fill out the new patient form and leave the rest on us.

We assure to protect your smile for now and ever! Tooth Buds dentistry is compassionate to provide you with healthy dental treatments exceeding your expectations.

Connect now to get the consultations!

If you’re a new patient to tooth buds dentistry Dental, please complete and submit your COVID-19 Screening Form first before completing your new patient form for your first appointment.

Are you a current or new patient?

How did you hear about our clinic?*

Patient Contact Information


Best way to contact you:

Marital Status

Insurance Information

Primary Insurance Company

Insurance Policy Holder

Secondary Insurance Company Information

Insurance Policy Holder

Financial Information

Person responsible for account

Preferred Method of Payment

Dental History

Please check any of the following problems that may apply to you.

If you could change your smile, you would….

Do you have, or have you had any of the following?

How important is your dental health to you?

Where would you rate your current dental health?

Medical History

Are you currently being treated for any medical condition or have you been treated within the past year?*

Has there been any change in your general health in the past year?*

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Do you have any allergies?*

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Do you have or have you ever had asthma?*

Do you have or have you ever had any heart or blood pressure problems?*

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

Do you have a prosthetic or artificial joint?*

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Have you ever had hepatitis, jaundice or liver disease?*

Have you ever been hospitalized for any illnesses or operations?*

Do you have or have you ever had any of the following? Please check all that apply.

Are there any conditions or diseases not listed above that you have or have had?

Do you smoke or use other nicotine products?

Do you identify as a patient with a disability?

General Release

I agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.*