Patient Intake Form

PERSONAL INFORMATION

Legal Name *

Preferred Name *

Best Contact Phone Number *

Alternate Phone Number

Date of Birth *

Email

Would you like correspondence delivered via email?:
YesNo

Address *

City *

Province *

Postal Code *

Dental Insurance *
YesNo

Marital Status (for insurance purposes):
SingleMarriedCommon LawWidowed

WE CAN BILL YOUR INSURANCE COMPANY DIRECTLY IF YOU CAN PROVIDE US WITH YOUR INSURANCE CARD. PLEASE PRESENT IT WITH THIS FORM FOR US TO COPY

INSURANCE: In order to prevent any misunderstanding about your dental insurance, please note that all professional services provided are the financial responsibility of the patient or legal guardian. Full payment is due when services are rendered unless financial arrangements are made ahead of time. With your permission, we can contact your insurance provider on your behalf to determine eligibility and benefits.

APPOINTMENTS: Appointment times are reserved for you. If you are unable to keep an appointment please allow two business days notice to avoid a late-cancellation or missed appointment fee ($100/hour)

PERMISSION TO TREAT: This is to certify that I, the undersigned, consent to the performing of dental and oral surgery procedures that are necessary or advisable, including the use of local anesthesia. I authorize the release of any records that are relevant to the processing and payment of this claim held by the service provider, any appropriate health professional licensing or regulatory body for the purpose of administrative audit.

If a minor, please enter parent's name:

Who can we contact in case of an emergency?

Emergency phone number:

Who can we thank for referring you to our practice?

DENTAL HISTORY AND INFORMATION

Who was your previous dentist?

How long since your last dental visit?

What was done at that time?

Are you interested in Invisalign, whitening, veneers, Botox or any of our other cosmetic services?
YesNo

Have you ever been told that you have gum disease?
YesNo

Are you having any problems with your teeth at this time? Please describe.

Please describe what you would like to achieve

MEDICAL INFORMATION

Name of your physician

Date of your last physical

Are you taking any medications? *
YesNo

If yes, please list

Do you smoke?
YesNo

If yes, how many per day?

Do you use cannabis?
YesNo

Are you allergic to latex? *
YesNo

Are you allergic to any medications? *
YesNo

If yes, please list

Do you or have you ever had any of the following:

Do you have any other medical condition that we should be aware of?

Please type your full legal name to indicate that you have read and agree with the above

Name *

Make Your Dream Smile A Reality!

Contact us today for Cosmetic Dentistry Services.

Book an Appointment or Call Us: (604) 894-6933

Book An Appointment See How We Can Help

7415 Prospect St., Pemberton, BC V0N 2L0

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+1 (604) 894-6933

Have a question? Call us now!

Mon - Fri: 9am - 5pm
Sat: By Appointment

Closed on Sun and Stat Holidays