Mon–Tue: 9–5 | Wed: 9–4 | Thu: 9–5 | Fri: 9–4

778-910-2726

778-653-9700

101-10626 City Pkwy Surrey

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You and your family might be eligible for the new government dental plan | visit page or call us or fill the form to find out.​   

New ​Patient Form

We at City Parkway Dental, look forward to taking care of your oral health care needs and welcome you to our team of professionals. We are committed to doing our very best to achieve a lifetime of optimal health for our patients. Kindly take the time to read and fill the entire form to help us do our best. Thank you.

    Personal Information

    Gender *

    Emergency contact OR Responsible party if under the age of 18

    Or Google?

    How would you assess your general health?




    Insurance Information

    Primary Plan

    Secondary Plan

    No Plan?

    I understand that payment is due at the time treatment is rendered. No exceptions.

    Cancellation Policy:

    It is our optimal goal to provide you and your family with the highest quality of dental care, while maintaining a friendly and relaxing environment. To keep our standard of care to a level which best serves your dental needs, we ask that you observe the following:

    Our clinic requires a minimum of 2 business days’ notice if an appointment must be cancelled or rescheduled. A short notice cancellation by one patient means another patient who is suffering or is in pain has missed an opportunity to be seen by the doctor. We feel very strongly about it and to deter people from such practice, we assess a fee of $75.00 to any short notice cancellation. Exceptions however will be made for illness or personal tragedy.

    In the event that a patient does not show up to their scheduled appointment on a second occasion, we may ask the patient to find a different dental office to serve them at which point our administrative staff will be happy to forward the patient’s records to the new dental office.

    Please note: Insurance companies do not cover the cost of missed or cancelled appointments; therefore, payment is made the patient’s responsibility prior to rescheduling.

    Patient Acknowledgements:

    To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health or other pertinent information, I will inform the doctors at my next appointment without fail.

    ​By initialing the insurance information, I am acknowledging that I have read and understood the statement pertaining to my insurance status.

    I have read and understood the cancellation policy.

    Treatment Policy: I authorize the doctor to take X-rays, study models, photographs, or other diagnostic materials deemed appropriate by the doctor to make a thorough diagnosis of my dental health condition. Upon my verbal agreement following discussion of recommended treatment, I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the services required for my dental health. I further authorize and consent that the doctor chooses and employs such assistance as deemed fit.

    (Parent or Guardian if the patient is under 18)

    City Parkway Dental

    Dental Office Personal Information Consent Form

    We are committed to protecting the privacy of our patients' personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law.

    We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, and e-mail addresses and patient photographs (collectively referred to as "Contact Information"). Contact information is collected and used for the following purposes:

    1. To open and update files.

    2. To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts.

    3. To process claims for payment or reimbursement from third party health benefit providers and insurance
    companies.

    4. To send reminders to patients concerning the need for further dental examination or treatment.

    5. To send patients informational material about our dental practice.

    Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patients' behalf.

    Financial information may be collected in order to make arrangements for the payment of dental services.

    We collect information from our patients about their health history, their family health history, physical condition, and dental treatments. (Collectively referred to as “Medical Information”) Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment.

    Patients’ Medical Information is disclosed:

    1. To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of dental treatment or has asked us to submit a claim on the patients’ behalf.

    2. To other dentists or dental specialists if the patient with their consent has been referred by us to the
    other dentistor dental specialist for treatment.

    3. To other dentists and dental specialists where those dentists have asked us, with the consent of the patient,
    to provide a second opinion.

    4. To other health care professionals such as physicians if the patient, with their consent, has been referred by
    us toother health care professional for either a second opinion or treatment.

    If we are ever considering selling all or part of our dental practice qualified potential purchasers may be granted access, as part of the due diligence process, to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all of the information.

    Dentists are regulated by BCCOHP whom may inspect our records and interview our staff as part of the regulatory activities in the public interest.


    I consent to the collection, use and disclosure of my personal information as set out in this form.