Dentisterie @ Casselman

98 Lafleche Blvd

Casselman, ON K0A 1M0

613-764-6600

Book a Stress Free Appointment Today

New Patiant Form

  • PATIENT INFORMATION
  • MEDICAL RECORD TRANSFER
  • MEDICAL AND DENTAL HISTORY

PATIENT INFORMATION

Please take a moment to enter your information in order to help us ensure the quality of your care


MEDICAL RECORD TRANSFER

Please allow us to get your past medical record


MEDICAL AND DENTAL HISTORY

Please take a moment to let us know about your medical/dental history so we may serve
you more efficiently and in a way that looks out for your overall health and well being.


Can you tell us how anxious you get, if at all, with your dental visits?

Please indicate by checking off the appropriate box


Your physical condition