Patient Registration Form

The information that is requested on this questionnaire is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

Patient Registration Form - Fill Online : By choosing this option you can fill and submit the Patient Registration information online. A new popup window will open with the Patient Registration Form, fill in the information and submit the form. A copy of the information submitted shall be emailed to you for your records.

Patient Registration Form - Fill Offline : By choosing this option you can download a blank Patient Registration Form. Please print and fill in the form manually and submit the form at the reception when you arrive at the Dental Office.


Patient Registration Form - Fill Online Patient Registration Form - Fill Offline
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GET HELP TODAY WITH FINANCING YOUR DENTAL TREATMENT
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King Street Dental Centre
Get a free Free Teeth Whitening Kit or Electric Toothbrush with new Patient Exam, Cleaning, and X-rays.
WHY CHOOSE KING STREET DENTAL CENTRE
  • Direct Insurance Billing
  • Student Discounts
  • Senior Discounts
  • Emergency Priority
  • Children Friendly
  • State-of-the-art Clinic
Request Appointment
Thank You. We will contact you as soon as possible.
FREE TEETH WHITENING KIT OR ELECTRIC BRUSH WITH NEW PATIENT EXAM
Terms and conditions apply. Call for details.
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