Always a Warm Welcome and Gentle Care

WELCOME

New Patients

Eagle Family Dentistry in Newmarket is currently accepting new patients of all ages; if you haven’t booked your dental appointment yet, you can do so conveniently, using our online form. Call us today to learn more about us.

Eagle Family Dentistry - New Patient Form

Mr.
Mrs
MS
Miss
Dr.
All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all insurance information. We do not have access to your private insurance policy information unless provided to us.
I understand, certify that I (or my dependent) have insurance coverage and assign directly to Eagle Family Dentistry all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Eagle Family Dentistry to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
New choice
Website
Internet
Yellow pages
Referral
Sensitivity
Grinding or clenching teeth
Tooth pain or discomfort when chewing
Bleeding, swollen or irritated gums
Headaches, earaches, or neck pain
Loose or shifting teeth
Jaw joint pain (clicking or cracking)
Bad breath or taste in the mouth
Broken teeth or fillings
Yes
No
Sometimes
Yes
No
Make your teeth whiter/brighter
Make your teeth straighter
Close Spaces
Replace fillings
Repair chipped teeth
Replace missing teeth
Replace crowns
Have a smile makeover
Other
AIDS
Rheumatic Fever
HIV Positive
Excessive Bleeding
Arthritis
Stomach Problems
Liver Disease
Heart Conditions
Blood Disorders
Tuberculosis
Pregnant
Hepatitis A/B
Diabetes
Allergies
Seizures
Jaundice
Fainting
Artificial joints
Stroke
Low blood pressure
Heart murmur
Cancer
Ulcers
Respiratory problems
High blood pressure
Emphysema
Anemia
Snoring or sleep apnea
Kidney disease
Glaucoma
Asthma
Thyroid disease
Pacemaker
Heart disease
Chemotherapy
Other
Aspirin
Sulpha drugs
Codeine
Local anaesthetic
Penicillin
Latex
Other
Yes
No
Yes
No
Yes
No
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize Eagle Family Dentistry to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.

Promotions and Special Offers

 New patient special! Dental cleaning for $120. Limited time offer.

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VISIT US

Eagle Family Dentistry
340 Eagle Street West Unit 11
Newmarket, ON, L3Y 7M9

Opening hours

Monday – Friday: 10 AM – 7:00 PM
Saturday: 10 AM – 4:00 PM
Sunday: Closed

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