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Dental Square

New Patient Form

    DENTAL SQUARE

    Welcome to our office! To assist us in serving you, please complete the following confidential information.

    PATIENT INFORMATION

    Use this form to screen patients before their appointment and when they arrive for their appointment

    Patient Last name

    First name

    Sex

    Birth Date

    Home Phone

    Cell Phone

    E-Mail

    Address

    City

    Prov.

    Postal Code

    Employer/School

    Occupation

    Work Phone

    Spouse Name

    Spouse Employer

    Whom may we thank for referring you to our office?

    Emergency Contact Name

    Relation

    Phone

    DENTAL HISTORY

    Reason for today’s visit

    Former Dentist Name

    Date of last dental visit

    Date of last cleaning

    Date of last dental X-ray

    Do you have or have you had any of the following? (Please check any that apply)

    Do you have any dental related issues/concerns not listed above?

    MEDICAL HEALTH HISTORY

    Are you allergic to, or have you reacted adversely to:

    Other:

    Are you taking any of the following?

    Other:

    Women:

    May be pregnant, expected due date:

    Name of the Physician:

    Phone number:

    Do you have any disease, condition, or problem not listed above?

    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist.

    Signature of patient (or parent)

    Date:

    Reviews

    Client Testimonials

    Posted on Google Google
    Angela Sahadeo profile picture
    Angela Sahadeo
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    Lovely clinic and the staff is great. Dr.Giridhar Ponnam and the hyginiest Preet are wonderful in their work. I have great experience since I am visiting here for more than 10 years.
    Posted on Google Google
    Aarusha Senthuran profile picture
    Aarusha Senthuran
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    My family has been going here for over 10 years. Everyone is highly professional, respectful and gets the job done fast and effectively. The hygienists are all very specialized in their field and the doctor shows pride in making sure that all of their patients receive their treatment and preferences alongside it. I had no concerns with anything. I highly recommend booking dental appointments here 😊
    Posted on Google Google
    Jay Jivani profile picture
    Jay Jivani
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    Very good Dr. I would recommend visiting. Very fine treatment and staff
    Posted on Google Google
    Obeidullah Shariff profile picture
    Obeidullah Shariff
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    I would like to sincerely thank and appreciate my dental hygienist Roma for the wonderful job she does every time I visit. Since my teeth are quite sensitive, she takes extra care and precaution to make sure the cleaning is as comfortable as possible. I especially appreciate that she does the cleaning manually when needed, rather than using methods that could make my teeth more sensitive or cause discomfort. Her experience, patience, and attention to detail really make a difference. She always takes the time to understand my sensitivity and works carefully to ensure I am comfortable throughout the appointment. Thank you for your excellent care, professionalism, and dedication. I truly appreciate the wonderful work you do and would highly recommend her to anyone looking for an experienced and caring dental hygienist. The entire staff is friendly and welcoming, which makes every visit comfortable and stress free. Obeidullah and Musrath Shariff
    Posted on Google Google
    Briton Facey profile picture
    Briton Facey
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    ⭐⭐⭐⭐⭐ Ever since moving to East Brampton, Dr. Giridhar Ponnam and his incredible team have taken exceptional care of my family’s dental and oral-hygiene needs. Their professionalism, dedication, and commitment to excellent dental health and, of course, beautiful smiles are truly second to none. What distinguishes Dr. Giridhar, however, goes far beyond dentistry. Over the years, he has consistently taken a genuine interest in my children, always remembering to ask about their social development, education, and overall well-being. He never seems to miss a beat, and that personal touch has never gone unnoticed. Dr. Giridhar is not simply an outstanding dentist; he is a compassionate professional who genuinely cares about the people behind the smiles. He consistently goes the extra mile, and through the years, that exceptional care has transformed a professional relationship into a treasured friendship with our family. Five stars hardly seem enough. I wholeheartedly recommend Dr. Giridhar Ponnam and his wonderful team. Thank you for taking such excellent care of our family and for always giving us another reason to smile!
    Posted on Google Google
    Kaysha's Life “KAYSHA'S LIFE” profile picture
    Kaysha's Life “KAYSHA'S LIFE”
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    Best dentist ever! They take care of me and my children so good. Keep our teeth straight and our smiles clean 👍🏽
    Posted on Google Google
    lubana agamdeep profile picture
    lubana agamdeep
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    I really appreciate dr Aman and Dr Manisha. They are very professional in work and both are more than a family since I am visiting from a long time. Must choose this clinic for their best services and excellent care. Even the receptionist staff is very cooperative and flexible.
    Posted on Google Google
    Prabh Sidhu profile picture
    Prabh Sidhu
    Google star 1Google star 2Google star 3Google star 4Google star 5Trustindex verifies that the original source of the review is Google.
    I have been coming to this place from last 14 years . Roma hygienist is the best . My kids also come to this place . I highly recommend this place to everyone for their teeth services . I have got my teeth feelings done from dr Giridhar. He is the best doctor in town .

    We’re Here to Help You Smile

    We PROUDLY accept the Canadian Dental Care Plan (CDCP).

    You may qualify for covered dental care, including:

    • Preventive care (cleanings, exams, X-rays)
    • Restorative treatments (fillings, crowns)
    • Root canals, dentures & extractions
    • Emergency dental care

    Book your appointment Today!