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Your journey begins here.
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*
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Step
1
of
3
- Basic Information
33%
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Home Phone
*
Other Contact Number
Email Address
*
Who can we thank you referring you?
*
Describe a few words what role we can play in your dental health:
*
Describe your dental hygiene routine in few words?
*
On a scale of 1 to 10 how would you rate your teeth, gums or oral health
*
Please enter a number from
1
to
10
.
Describe any teeth sensitivities/pain that you have
*
Are you more interested?
*
Preventing pain/problems?
Fixing pain/problems as the arise?
What best describes you?
*
We are giving you the smile you once had?
We are creating the smile you've always wanted?
What type of dentistry are you looking for?
Highest standard of Dentistry available
Only that which has an insurance benefit
Least expensive
Are you missing any permanent teeth?
*
Has there been any injuries to your face/teeth in the last 12 months?
*
Any sensitivity to local anaesthetics
*
Is there anything else you would like us to know, to provide you with the care you desire?
*
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/Vaping
Sinusitis
Tuberculosis
Diabetes
Blood Pressure
Hepatitis A/B/C
Bleeding or Bruising
Fainting
Rheumatic Fever
Artificial Joints
Are you pregnant at this time?
*
No
Yes
Do you have a Latex Allergy?
*
No
Yes
Other Allergies? Please Indicates
*
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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