Patient Form

Welcome to Shelburne Village Dental, dentistry you can trust.

1. About You

Patient’s name:
Home address:

2. Dental Insurance

3. Telephone/Email

In the event of an emergency, is there someone who lives near to you that we could contact?

4. Medical History

1. I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
3. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and employ such assistance as required to provide proper care
4. I agree to the use of local anesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
5. Payment is due in full on date of service with the following payment options: CASH, VISA, MASTERCARD, INTERAC Our office is equipped to submit insurance claims electronically if we have your correct information. (Note: Not all insurance companies do electronic claims.) PLEASE DO NOT HESITATE TO ASK OUR STAFF SHOULD YOU HAVE ANY QUESTIONS REGARDING PAYMENT.
6. Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise it will be necessary to charge for time lost.
7. I authorize release, to my dental benefits plan administrator & the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the name dentist. This authorization will continue in effect until the undersigned revokes the same.

Meet The Doctor

Dr. Faisal Waseem

At Shelburne Village Dental, we practice general, family and cosmetic dentistry. We aim to develop life long relationships with our patients based on trust and integrity.

Our professional staff use the latest in dental technology to provide a safe and pleasant experience for you and your family.


Our patients will always be our first priority. We are devoted to creating an exceptional experience with every patient that walks into our office.

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