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New Patient Form

Your journey begins here.

Step 1 of 2 - Basic Information

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Patients Name*
First Name Last Name
Birth Date*
MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Other Contact Number
Email Address*

Referral Source*
Purpose of your visit*
How often do you brush*
Any sensitivity to local anaesthetics?*
- Yes
- No
Has there been any injuries to your face/teeth in the last 12 months?*
Are you missing any permanent teeth?*
- Yes
- No
If yes, is this congenital?*
Are your teeth sensitive to:
Check all that apply
- Hot
- Cold
- Bite Pressure
Do you clench*
- Yes
- No
Are you troubled with Jaw Pain?*
- Yes
- No
Do you have a side you chew on more?*
- Yes
- No
What type of dentistry are you looking for?*
- Highest standard of dentistry available
- Only that which has an insurance benefit
- Least expensive
Do you expect to keep your teeth for a lifetime?*
- Yes
- No
If yes, why is this important to you?*
Are you satisfied with the appearance of your teeth?*
- Yes
- No
Are you satisfied with the health and functionality of your teeth?*
- Yes
- No
Are we recreating the smile you once had?*
- Yes
- No
Are we giving you a smile you always wanted?*
- Yes
- No
Have you been treated or diagnosed for any of the items listed below:
Please check all that apply to you, past and present
- AIDS/HIV Risk
- Bone Disorder
- Heard Condition
- Kidney Disease
- Anxiety
- Lung Problems
- Cancer
- Epilespy
- Smoking
- Sinusitis
- Tuberculosis
- Diabetes
- Blood Pressure
- Hepatitis A/B/C
- Bleeding or Bruising
- Fainting
- Rheumatic Fever
- Artificial Joints
Are you pregnant at this time?*
- Yes
- No
Do you have a Latex Allergy*
- Yes
- No
Other Allergies? Please indicate
List of current medications
Terms & Conditions*
- By checking this box, I consent all the information provided on this form is correct and up to date. I hereby authorize Peace Arch Dental to contact my dental insurance should they need access to any information regarding my policy and coverage. I also consent to the use of my photos for dental records, educational and business purposes.

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info@peacearchdental.com (604) 531-0511

Location

#302 – 1656 Martin Drive
V4A 6E7 — Surrey BC

Hours

Mon - Thu | 8:00am - 5:00pm
Friday | 8:00am - 4:00pm

Location

#302 – 1656 Martin Drive
V4A 6E7 — Surrey BC

Hours

Mon - Thu | 8:00am - 5:00pm
Friday | 8:00am - 4:00pm

Home of Peninsula Dental Imaging

Technology that sets you and your teeth up for the best possible outcome.

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