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New Patient Form

Fill out the New Patients Form

Besma Dental Family Centre is always happy to welcome new patients and help them with their dental needs. We provide cosmetic dentistry, general dentistry, and sedation services at our dental clinic in Welland. Book an appointment today for your first dental visit. You can fill out the form given on this page and provide us with information about you and your dental health.


Fill out the form given below or download the form.

MEDICAL AND DENTAL HISTORY

Home Address

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No

MEDICAL HISTORY: The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected. Please fill in the entire form.

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No
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No
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No
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No
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Chest pain
angina
rheumatic fever
lung disease
stomach ulcers
Drug/alcohol dependency
Heart attack
tuberculosis
arthritis
osteoporosis medications
stroke
cancer
seizure(epilepsy)
shortness of breath
heart murmur
steroid therapy
kidney disease
pace maker
diabetes
thyroid disease
organ transplant
malignant hypothermia
mental health disorder
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No
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No

FOR WOMEN ONLY:

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No
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DENTAL HISTORY

Good
Fair
Poor
Bleeding Gums
Crooked Teeth
Cosmetic
Loose Teeth
Bad Breath
Food Trapping
Sensitive Teeth
Toothache
Loose Dentures
Missing Teeth/Spaces
Want Whiter Teeth
Patient Consent

Need Dental Care in Welland?

We are accepting new patients. 

Book Your Appointment

Besma Family Dental Centre

Address: 167 Riverside Dr

Welland, ON  L3C 5E1

Phone: 905-734-9214

Business Hours

Monday 08:30 AM - 06:00 PM

Tuesday 09:00 AM - 07:00 PM

Wednesday 09:00 AM - 07:00 PM

Thursday 08:30 AM - 06:00 PM

Friday 09:00 AM - 04:00 PM

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