Patient Registration

Please register by completing our secure online Patient Registration Form. On your first visit we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

    PERSONAL INFORMATION

    Date: Status: Prefix:

    Given Name:  

    Family Name:

    Address: Apt:
    City: Province: Postal Code:

    Date of Birth:

    Telephone Residence:

    Telephone Business: Ext.

    Occupation: Referred By:

    Person responsible for account:
    SelfOther

    Dental Insurance: NoYes.

    Name of Insurance Company:

    Reason for today’s visit:
    ExaminationEmergencyOther

    Physician Name:

    In case of emergency please notify:
    Name: Relationship:

    Telephone:

    MEDICAL HISTORY

    The following information is required by the dentist to assist in proper diagnosis and treatment. All information is confidential.

    1. Are you presently under the care of a physician? YesNo

    2. Have you ever been hospitalized? YesNo
    Specify:

    3. Do you have a heart or circulatory problem of any kind? YesNo

    4. Have you ever had rheumatic fever? YesNo

    5. Do you have any allergies? YesNo
    Specify

    6. Are you presently taking any kind of medication? YesNo

    7. Do you have bleeding problems? YesNo

    8. Are you pregnant? YesNo

    9. Have you ever had a reaction to any knd of medicine? YesNo
    Specify:

    10. Do you presently or have you ever had (Hold CTRL to make multiple selections):

    11. Have you ever had concussion? YesNo

    12. Have you ever fainted? YesNo

    13. have you ever had any illness not included above? YesNo

    14. have you ever had local anaesthetic? YesNo

    PATIENT CERTIFICATION AND APPROVAL
    I, the undersigned certify the all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

    Patient (Parent, Guardian) Signature Date:

    PATIENT (GUARDIAN) CONSENT (FOR MINORS)
    I, the undersigned, consent to the performing of dental and oral surgery procedures agree to be necessary or advisable, including the use of local unaesthetic as indicated, and I will assume responsibility for fees associated with these procedures.

    Parent (Guardian) Signature Date:


    Your Email (required)

    Our Mission

    York Hill Endodontics has been delivering quality endodontic services since 1965. Our mission remains to continue providing the same exceptional endodontic care to any patient entering our doors. Come by and experience the quality care that has served Torontonians for 50-plus years.

    Our Vision

    The thought of endodontic treatment shouldn't make patients worried. Our team will work with patients to deliver the most comfortable treatment possible in our modern environment. York Hill Endodontics employs the latest technologies that make treatment convenient and pain-free. Our vision is that every patient that seeks our help will leave with a healthy smile.

    Our Values

    • Top-quality endodontic treatment
    • Provide a comfortable experience in a modern setting.
    • Educate patients to make the right decisions to maintain a healthy set of teeth.
    • Provide a safe and clean environment for patients and staff.
    • Promote long-lasting relationships with patients and referring dentists.

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