New Patient Form

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New Patients

Patient Information

Health Information

What is your estimate of your general health?

Do You Have or Have You Ever Had:

Hospitalization for illness or injury *
An allergic reaction *
If yes, to what: *
Heart problems, or cardiac stent within the last six months *
History of infective endocarditis *
Artificial heart valve, repaired heart defect (PFO) *
Pacemaker or implantable defibrillator *
Orthopedic implant (joint replacement) *
Rheumatic or scarlet fever *
High or low blood pressure *
A stroke (taking blood thinners) *
Anemia or other blood disorder *
Prolonged bleeding due to a slight cut (INR > 3.5) *
Pneumonia, emphysema, shortness of breath, sarcoidosis *
Chronic ear infections, tuberculosis, measles, chicken pox *
Asthma *
Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) *
Kidney disease *
Liver disease *
Jaundice *
Thyroid, parathyroid disease, or calcium deficiency *
Hormone deficiency *
High cholesterol or taking statin drugs *
Diabetes (HbA1c= ) *
Stomach or duodenal ulcer *
Digestive disorders (i.e. celiac disease, gastric reflux, bulimia) *
Osteoporosis/osteopenia (i.e. taking bisphosphonates) *
Arthritis *
Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) *
Glaucoma *
Contact lenses *
Head or neck injuries *
Epilepsy, convulsions (seizures) *
Neurologic disorders (ADD/ADHD, prion disease) *
Viral infections and cold sores *
Any lumps or swelling in the mouth *
Hives, skin rash, hay fever *
Hepatitis *
HIV / AIDs *
Tumor, abnormal growth *
Radiation therapy *
Chemotherapy, immunosuppressive medication *
Emotional difficulties *
Psychiatric treatment *
Antidepressant medication *
Alcohol abuse / recreational drug use *

Are You:

Presently being treated for any other illness *
Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough or diarrhea)) *
Taking medication for weight management *
Taking dietary supplements *
Often exhausted or fatigued *
Experiencing frequent headaches *
A smoker, smoked previously or use smokeless tobacco *
Considered a touchy / sensitive person *
Often unhappy or depressed *
Taking birth control pills *
Currently pregnant *
Being treated for a prostate disorder *

List all medications, supplements and/or vitamins taken within the last two years

Please advise us in the future or any change in your medical history or any medications you may be taking.

Consent for Services

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
I hereby assign my benefits, payable from claims submitted electronically, to the Dentist and authorize payment directly to him/her.
I grant my permission to you or your assignee, to telephone me at my home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.

Brush, floss and smile. Everyday.

Studio Hours

MONDAY 8:00am - 5:00pm
TUESDAY 7:00am - 5:30pm
WEDNESDAY 7:00am - 5:30pm
THURSDAY 7:00am - 7:00pm
FRIDAY 8:00am - 3:30pm
SATURDAY 9-2pm Some Saturdays


#206 - 15350 - 34th Ave
Surrey, B.C. V3S 0X7