A parent, guardian or substitute decision maker will be responsible for decisions on my treatment
First Name
Street Address
Home Phone
Email Address
Last Name
Work Phone
Emergency Contact
Date of Birth
Postal Code
Cell Phone
Phone Number
How did you hear about our practice?
Preferred method of contact? (Check one):
Do you have dental insurance?
(If yes, please provide us with your dental insurance card and benefit booklet).

Dental History

What is the reason for today’s visit?
When was your last dental checkup?
Reason for leaving your last dentist?
Do you regularly have dental cleanings done?
Do you like your smile?
If no, please explain what you would like to change
Have you had a bad experience in a dental office?
If yes, please explain...

Medical History

Do you smoke or use tobacco in any other form?
Are you pregnant?
(Women) Do you use prescribed birth control?
Are you nursing?
If you ever had any of the following medical conditions listed below, please check:
Please list any serious medical conditions or recent surgeries you had:
Are you taking any prescription medication or over the counter drugs?
If yes, please list each one:
Have you ever been told by a physician that you require antibiotics prior to dental treatment?
Do you have any allergies to the following? If so please check:
Please list any other allergies:


Insurance Agreement:
Your insurance coverage is a contract between you and your insurance carrier. Not your insurance carrier and the Dentists. Keeping this in mind and providing your carrier allows assignment of benefits to us, we are willing to extend the same courtesy to you. You are, however, fully responsible for any charges incurred while at this office. You are also fully responsible for any differences not paid to the Dentist by your insurance carrier. All claims will be sent electronically unless your carrier does not allow this method. Before we can extend you the courtesy of assignment of benefits we must receive full information of your dental insurance coverage and complete details of your package.
Appointment Cancellation / Missed Policy:
Your appointment time will be reserved especially for you. If you are unable to keep your appointment or need to reschedule we will require 48 HOURS notice otherwise it may be necessary to charge for time lost.
Privacy Act and Consent:
Privacy of you and your personal information is an important part of our office providing you with quality dental care. Stroud Dental understands the importance of protecting your personal information. We are committed to collecting using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information about you is collected:

  • We only share information with your consent

  • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols:

  • Our privacy protection complies with privacy legislation, standards of our regulatory body, the College of Dental Hygienists of Ontario and/or The Royal college of Dental Surgeons of Ontario, and the law.

Please be assured that every staff member is committed to ensuring that you receive the best quality care, and please do not hesitate to discuss our policies with myself or any staff member.
Stroud Dental will collect, use and disclose information about you for the following purposes:

  • To deliver safe and efficient patient care, to identify and ensure continuous high quality service

  • To assess your health needs and provide health care, to advise you of treatment options

  • To enable us to contact you and maintain communication with you, including distributing health-care information and to book and confirm appointments

  • To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally

  • To communicate with other treating health-care providers, including physicians, pharmacists, referring general dentists an specialists

  • To allow us to efficiently follow-up for treatment, care and billing

  • For teaching and demonstration on an anonymous basis

  • To complete and submit dental claims for third party adjudication and payment

  • To comply with legal and regulatory requirements, including the delivery of patients charts and records to The Royal College of Dental Surgeons of Ontario and/or The College of Dental Hygienists of Ontario in a timely fashion when required, according to the provisions of the Regulated Health Professions act

  • To comply with agreements/undertakings entered into voluntarily by the member with the regulatory body for regulatory and monitoring purposes

  • To permit potential purchasers, practice brokers or advisors to evaluate the practice and potentially allow such people to conduct an audit in preparation for a practice sale

  • To deliver your charts and records to the staff’s insurance carriers to enable the insurance company to assess liability and quantify damages if any

  • To prepare materials for the Health Professions Appeal and Review Board ( HPARB)

By reading and signing this consent, you agree to have given your informed consent to the collection and /or disclosure of your personal information for the purposes that are listed. You may withdraw your consent for use and disclosure of your personal information and we will explain the ramifications of that decision, and the process.
Patient Signature:

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  • Preferred time slot
  • 9 a.m - 10 a.m
  • 10 a.m - 11 a.m
  • 11 a.m - 12 p.m
  • 12 p.m - 1 p.m
  • 1 p.m - 2 p.m
  • 2 p.m - 3 p.m
  • 3 p.m - 4 p.m
  • 4 p.m - 5 p.m
  • 5 p.m - 6 p.m
  • 6 p.m - 7 p.m
  • Preferred day
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday

Patient Reviews

Awesome company
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Carina Barros

Awesome company and super friendly staff!

Very good team!
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Breanna Thorn

I went to Stroud dental on monday for the first time in 13 years..... I was so afraid to go. The experience was amazing. They made me feel comfortable. Jess is very good at her job and gentle. I didnt feel embarrassed or shamed at all. They made sure I got my x Ray's up to date and informed me, my old x Ray's had baby teeth in them. Very good team! Happy I went in and faced my fears.

We highly recommend Stroud Dental!
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Shawna Toole

My husband is terrified of going to the dentist and after convincing him to go to Stroud Dental for the first time he has now been 3 times! The staff is absolutely amazing and made him feel safe and comfortable! He actually looks forward to going to the dentist now. Dr. Peleg rocks and the girls are a hoot. We highly recommend Stroud Dental!

The best experience I have ever had!
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Cassandra Dickson

Stroud dental was the best experience I have ever had! The staff are very knowledgeable and friendly, it was very clean, fast and efficient. thank you for making my smile beautiful! I would highly recommend this dental office.

A wonderful place to bring your children.
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Logan Beau

Stroud Dental is a wonderful place to bring your children. The staff are amazing with my sons, one of which is on the autism spectrum. They are patient and understanding of his quirks. If you’re looking for a great place for dental work check out Stroud Dental.

We couldn’t be more happy.
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Keith Shay Smeets

We have been patients of Stroud Dental for over five years!
They have the most amazing team, who make you feel comfortable, welcomed and part of their family!
They are so patient with our 15 month old daughter, and us!
We couldn’t be more happy with everyone at Stroud Dental!

Family, friendly!
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Dana Donaldson

Family, friendly! Have always been great with my kids. Always a pleasant experience.

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