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Home
About Us
Team
Services
General Dentistry
Preventive
Restorative
Extractions
Specialized Dentistry
Invisalign™ Treatment
Periodontal
Endodontics
Oral Surgery
Cosmetic Dentistry
Veneers
Composite Bonding
Philips Zoom™ Whitening
Prosthosontics
Dental Implants
Fixed Bridges
Dentures
Other Services
Digital Imaging
CBCT Scan
Oral Cancer Screening
Resources
Insurance & Finance
Patient Forms
Blog
Gallery
Meet The Doctors
Tour the Office
Contact
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Patient Resources
Patient Forms
Registration Form
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Office Policy
appointments you have booked. All appointments are considered confirmed unless you have called to cancel or change your appointment. It is your responsibility to remember your scheduled appointment.
APPOINTMENTS - A full 2 OFFICE BUSINESS DAY notice is required to change or cancel any schedule appointments. – To avoid a cancellation fee. Cancellations that are left on office voice mail will not be accepted to change your scheduled appointment.
DENTAL INSURANCE: Your insurance company may not give our office information regarding your contract policies; this is under the Policyholder’s Privacy Act. When our office is checking your insurance eligibility, your insurance (if they disclose your insurance information to our office) is for the date we called and your insurance will give us the information they have on file. Due to limits and frequencies under your plan contract our office may not be able determine if all dental treatment may be covered under your plan contract due to this privacy act.
If we have problems with receiving payment from your dental plan for any treatment rendered, you understand you will pay the dentist directly and get reimbursed from your dental insurance.
Contact your insurance company or your plan benefits department if you need information regarding your policy.
OFFICE POLICY REGARDING AMALGAM (SILVER) VS COMPOSITE (WHITE) FILLINGS:
Composite (white) fillings on permanent molars are not covered under some plan contract. Insurance company rarely covers for composite (white) filling on back molar teeth. Your insurance plan will cover the equivalency of an amalgam (silver) filling.
There is a cost difference for this type of restoration which varies from $40.00 to $160.00 per tooth. This is to inform every patient: Our office does not do “AMALGAM/MERCURY” fillings.
You understand should you want to do this type of filling we will provide you a number to the BC Dental Association and if possible not guaranteed they may be able to refer to a dentist that does “amalgam/mercury” fillings.
ELECTRONIC BILLING
You are authorizing my dental office to send my dental claims to my insurance company electronically.
PATIENT RESPONSIBILITY
Inform us of medical changes, allergies, address and telephone changes and dental plan changes. Dental treatment may not be covered or may exceed your plan benefits. You understand that you are financially responsible to the dentist for the entire treatment rendered.
Payment for any treatment not covered needs to be paid when services rendered, unless payment plan has been previously arranged by you and the dentist.
Consent
*
I have read and fully understand the above office policy regarding my dental insurance & my patient responsibility.
Today's Date (DD/MM/YYYY)
*
Patient Full Name
*
Primary applicant please sign inside the box
*
Personal Information
First Name
*
Last Name
*
Middle Initial
Title
Mr.
Miss.
Mst.
Ms.
Mrs.
Dr.
Is this your legal name?
Yes
No
Birth Date (DD/MM/YYYY)
*
Sex
Female
Male
Street Address
*
City
*
Province
*
Postal Code
*
E-mail
*
Primary Phone Number
*
Secondary Phone Number
Job Title/Occupation
*
Current Employer/Company
Referred to clinic by (please check one):
Family/friend
Website
Family Dentist
Other
If Other
Name of referral:
Other family members seen here:
Insurance Information (Please give your insurance card to the receptionist)
Are you covered with dental insurance?
Yes
No
Do you have dual (secondary) insurance?
Yes
No
Name of Primary insurance (if applicable):
Subscriber’s name:
Subscriber’s Birthdate:
Group no.:
ID or certificate no.:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
Name of Secondary insurance (if applicable):
Subscriber’s name:
Subscriber’s Birthdate:
Group no.:
ID or certificate no.:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
In Case Of Emergency
Name of next of kin or friend:
Relationship to patient:
Home phone no.:
Work phone no.:
Consent
*
I certify that I have read and understand the above information to the best of my knowledge. The above questions and the health questionnaire have been accurately answered.I understand that providing incorrect information cans be dangerous to my health. I authorize the dentist too release any information including the diagnosis and the records of any treatment or examination rendered to me/or my child during the period of such dental care to third party payors and/or Health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand that I am financially responsible to my dentist for the entire treatment rendered on my behalf or my dependents.
Today's Date (DD/MM/YYYY)
*
Primary applicant please sign inside the box
*
Health Questionnaire
First Name
*
Last Name
*
Middle Initial
Date of Birth (DD/MM/YYYY)
Best Contact #:
E-mail Address:
Have you been examined and /or treated by a physician within the last year?
Yes
No
If yes, When?
Physician’s Name:
Physician’s Phone:
Have you ever been seriously ill or hospitalized?
Yes
No
If yes, When?
Do you require any antibiotic coverage before any dental treatment?
Yes
No
Are you on blood thinners?
Yes
No
If YES the medication you are taking:
Please check (√) if you have ever had any of the following:
Angina - Chest Pain
Arthritis
Artifical Joints (Hip/Knee)
Ashtma
Bruise easy
Cancer
Radiation / chemo treatment
Cold sores
Congenital heart condition
Cortisone/steroid therapy
Difficulty swallowing
Earaches
Feel thirsty much of the time
Frequent indigestion/vomiting
Heart attach or Stroke
Heart murmur / palpitations
High risk group of AIDS/HIV
Infectious/communicable disease
Inflammatory rhematism
Lung/breathing problems
Mitral Valve Prolapse
Nervous / Mental / Depression
Transplants i.e. Hip/Knee
Pacemaker/artifical valves
Prolong bleeding after injury
Persistent cough
Painful swollen joints
Rheumatic fever
Recent change in appetite
Severe headaches
Sinus trouble / Sore throats
Stomach / intestinal problems
Tendency to faint
Trouble hearing
Tumors or growth
Thyroid problem
Venereal Disease
Drug or Alcohol Addiction
Blood Pressure Problems
Yes
No
Type
High
Low
Diabetes
Yes
No
Type
Type 1
Type 2
Liver disease/ Hepatitis:
Yes
No
Type
Do You Smoke?
Yes
No
Sensitivites/Allergies
Aspirin
Codeine
Advil - Ibuprofen
Sulfa
Tylenol
Penicillin
Clindamycin/Erythromycin
Nitrous Oxide (anaesthetic gas)
Latex
Other (Not listed)
WOMAN ONLY: Are you pregnant?
Yes
No
*MEDICATIONS you are taking?
Is there anything else concerning your health not listed that you think the doctor should know about?
Yes
No
When was your last dental visit?
Have you had x-ray taken with in the last year?
Are you having dental discomfort or dental pain?
Have you ever experienced abnormal bleeding associated with previous extraction, surgery or trauma?
Yes
No
How many times do you brush a day?
How many times do you floss a day?
Do your gums bleed when brush or floss?
Never
Sometimes
Often
Do you have any oral habits: clenching, grinding, nail biting, thumb sucking?
Yes
No
Have you ever had professional tooth brushing & flossing instructions?
Yes
No
I am interested in dental sedation.
Yes
No
Have you had and problems with or unpleasant reactions to dental treatment?
Yes
No
Are you happy with the appearance of your teeth?
Yes
No
My primary concerns is:
Today's Date (DD/MM/YYYY)
*
Primary applicant please sign inside the box
*
