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Patient Registration Form
North Park Family Dental Care
9886 Torbram Road, Suite 101, Brampton, ON, L6S3L9
Tel. (905) 789-8116; Fax (905) 789-7677; email: Northpark@drcrisol.com ; website: www.drcrisol.com
Your cooperation in completing this form is essential to the provision of the highest standard of dental care. All information is strictly confidential and will remain with this office. Please do not hesitate to contact us if you require assistance in completing the form.
PERSONAL INFORMATION
Family Physician Information
Emergency Contact Information
Who may we thank for referring you? Please check appropriate box and indicate names on the right where applicable
BENEFITS
I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.
I hereby assign my benefits, payable from claims submitted electronically, to DR. CRISOL and authorize payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.