Mon - Fri: 9:00AM - 5:00PM
778-653-9700
778-910-2726
101-10626 City Pkwy Surrey
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Emergency Contact or Responsible Party if under the age of 18
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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
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Do you have any jaw joint problems? YesNoI’m not sure
Do you have bleeding gums? YesNo
Do you suffer from bad breath or halitosis? YesNo
How would you assess your general health? GoodFairPoor
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:"]
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Mon - Fri: 9:00AM - 5:00PM
778-653-9700
778-910-2726
101-10626 City Pkwy Surrey Mon - Fri: 9:00AM - 5:00PM 778-653-9700 778-910-2726 101-10626 City Pkwy Surrey