About you

The person receiving care — parents, you can register your child here.

First name

This field is required.

Last name

This field is required.

Date of birth

This field is required.

Gender

Please choose an option.

Preferred name (optional)

This field is required.

Street address

This field is required.

City

This field is required.

Province

This field is required.

Postal code

This field is required.

Mobile phone

This field is required.

Email

This field is required.

Is this patient under 18?

Yes No

Parent/guardian full name

A parent or guardian must accompany patients under 18 at the first visit.

This field is required.

Emergency contact

Someone we can reach if we ever need to.

Contact name

This field is required.

Relationship

This field is required.

Contact phone

This field is required.

Family physician (optional)

Name and clinic, if you have one.

This field is required.

Insurance & billing

We bill all plans directly — you pay only your co-portion.

Do you have dental coverage?

Yes — private/work insurance Yes — CDCP (Canadian Dental Care Plan) No coverage

Insurance company

This field is required.

Policy / group number

This field is required.

Member / certificate ID

This field is required.

Policy holder name (if not you)

This field is required.

Photo of insurance card (optional)

Front of card — JPG, PNG or PDF, max 10 MB.

Please attach a valid file.

CDCP member number

From your Sun Life CDCP card or letter.

This field is required.

Health basics

The short version — we'll go deeper in the medical history form or at your visit.

Do any of these apply?

Heart condition High blood pressure Diabetes Asthma or lung condition Bleeding disorder Allergies to medications Pregnancy None of the above

Please list your medication allergies

This field is required.

Current medications (or 'none')

Include doses if you know them — a photo of your medication list at your visit works too.

This field is required.

How do you feel about dental visits?

Totally fine A little nervous Very anxious — tell me about sedation

Consent & signature

The legal bits, in plain language.

I confirm the information provided is accurate to the best of my knowledge. I consent to Dentistry @ Manotick collecting and using this information to provide dental care, communicate with me about appointments, and bill my insurance where applicable, in accordance with their Privacy Policy. I understand I can update or withdraw consent by contacting the office.

I have read and agree to the above *

Your signature (or parent/guardian for minors)

Draw your signature with your finger or mouse.

New Patient Registration

About you

Emergency contact

Insurance & billing

Health basics

Consent & signature

Welcome to the Practice!