registration-adult - _Dr Jeffrey Tse D.D.S M.Sc Cert ORTHO F.R.C.D(C 650 Highway#7 East Suite 101 Richmond Hill Ontario Canada L4B 2N7 Tel

registration-adult - _Dr Jeffrey Tse D.D.S M.Sc Cert...

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_____Dr. Jeffrey Tse, D.D.S., M.Sc., Cert. ORTHO., F.R.C.D.(C)_____ 650 Highway #7 East, Suite 101, Richmond Hill, Ontario, Canada L4B 2N7 Tel: 905-771-SMILE (7645) Fax: 905-771-7442 Welcome To Our Office! Please Complete All Information On Both Sides Patient Information Patient’s Last Name:______________________ First Name:______________________ Preferred Name:_______________________ Sex : M / F Age:_____________ Birth Date (MM/DD/YYYY):______________________ S.I.N. ________________________ Home Address: ___________________________________ City & Province:_______________________ Postal Code:____________ Home Phone: ( )_____________________ Cell Phone: ( )_____________________ E-mail:__________________________ Employer: _________________________ Occupation: ________________________ Work Phone: ( )_____________________ Work Address: ____________________________________City & Province: _____________________ Postal Code:_____________ Emergency Contact: ___________________________ Relation: _____________________ Phone: ( )______________________ How Did You Hear About Us? Referred By: Your Dentist Friend / Relative Sign T.V. Commercial Web Site If Applicable, Spouse Name:_________________________ Occupation: ____________________ Phone: ( )_________________ If Applicable, Children In Family (Name & Age) ____________________________________________________________________ Does Any Relative Have A Bite Similar to Yours? Y / N Who (Relation & Age)?_______________________________________ Do You Have Other Friends Or Relatives Who Are/Were Treated Here? Y / N Name(s): _________________________________ Financial Information Primary Person Insured or Responsible For the Financial Account: Last Name: ________________ First Name: ________________ Address: _________________________________________ City & Province: _____________________ Postal Code:_____________ Phone: ( )___________________ Birth Date (MM/DD/YYYY):_______________________ S.I.N.________________________ Do You Have Dental Insurance? Y / N Does it Cover Orthodontics?

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