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New Patient Forms

Please select the form you wish to complete below.

Dental & Medical history
Dental Cancellation Policy
Dental Records Release

Dental & Medical History

Women:

Do you have, or have you had, any of the following? (Click all that apply)

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in my medical status.

Dental Appointment Cancellation Policy Agreement

Our patients are responsible for providing 48 hours notice for appointment cancellations. If you cancel or no show, we lose two patients, you and the person who could have been treated in that time slot. I acknowledge that without proper notice I may be charged a $125.00 fee per dental provider that is uncollectible by a third party and is my personal responsibility to pay. We do, however, understand that illness and emergencies occur and we do accommodate for those rare instances.

Our goal is to help you achieve optimum oral health.

Dental Records Release

I, 

herby authorize

to release my dental radiographs and/or records to Moss Dental. I also authorize the release of any dental radiographs and /or records for my dependants or for the patients for whom I am guardian

Please forward digital radiographs and date of complete exam to info@mossdental.ca

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