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:"]
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