Mon - Fri: 9:00AM - 5:00PM
101-10626 City Pkwy Surrey
Date of Birth
Emergency Contact or Responsible Party if under the age of 18
Friend Referral (Please provide name)GoogleSocial Media
Reason for current appointment
[texta rea textarea-396 "Reason for current appointment:"]
Do you have any oral habits such as clenching, grinding or thumb sucking?YesNo
Do you have any jaw joint problems?
YesNoI’m not sure
Do you have bleeding gums?
Do you suffer from bad breath or halitosis?
How would you assess your general health?
Have you been hospitalized in the last 3 years?YesNo
[textarea List all the medications you take (Please include prescription and over the counter) "Reason for current appointment:"]
Your message (optional)
It is our optimal
goal to provide you and your family with the highest quality of dental care,
while maintaining a frilly and lacing environment. To keep me standard of care
to a level which best serves your dental needs, ask that you observe the
Our clinic requires a minimum of 2 business days' notice if an
appointment must be canceled 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: Exception homer will be code 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.
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
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
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.
Signature Date (Parent or Guardian if the patient is under 18)