Contact & Medical Information Update Form

    Please use this form to update Donly Dental in the event of any changes to: medications, medical condition, insurance company and/or insurance coverage, phone number or address, or other relevant changes that may affect your care and correspondence with us.

    Your Name:

    Your Email:

    Date of Birth:

    Name of Patient if Different than Above:


    Update Phone Number:

    New Phone Number:

    Update Address (include number, street, city, and postal code):
    Street Address:

    Town/City:

    Postal Code:

    List of Medications and any new medical conditions/issues:

    Insurance Coverage or Insurance Company Changes:


    Covid Vaccination Status
    Current status of vaccination against Covid-19?

    Brand of Vaccine (if multiple, please write each brand):

    Date of Last Covid-19 Vaccine Dose:


    Contact Preference

    Would you like a different type of reminder/notification:
    TextEmailVoice Call

    Your Signature:
    Use your mouse to sign on computer, or finger on a mobile device


    Please make sure you've filled out all of the required fields.
    If you are still having trouble submitting the form, you can try a different browser.
    (Chrome is recommended).


    Monday:

    8:00am – 7:00pm

    Tuesday:

    8:00am – 7:00pm

    Wednesday:

    8:00am – 7:00pm

    Thursday:

    8:00pm – 7:00pm

    Friday:

    8:00am – 5:00pm

    Saturday:

    By Appointment Only

    Coming from out of town? Follow directions to Donly Dental. Now welcoming new dental patients from Delhi and Port Dover!

    Fill out this form and we'll get right back to you!





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