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778-340-2897 (778-222-7252 中文)[email protected]Suite #202, 814 15th St West, North Vancouver
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Smile Well Dental
North Vancouver Dental Clinic
Smile Well DentalSmile Well Dental
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    • Patient Intake Form
  • Home
  • About Us
  • Dental Services
    • Dental Implant
    • Invisalign
  • Gallery
  • Blog
  • Contact Us
  • COVID-19
  • Book a visit
    • Patient Intake Form

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  • Welcome! Thank you for selecting us..

    To help us provide you with the highest standard of dental care, please fill out this form completely. All information is strictly confidential. If you need assistance, please ask us and we will be happy to help you.

  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Reason for Visit

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Medical Information

  • DrugReason 
  • Dental History

  • Daily Habit Assessment

  • Please enter a number from 0 to 10.
  • Oral Discomfort Assessment

  • Supplement Assessment

    We are happy to talk with you about your dietary issues or your esthetic needs. As orofacial professionals, we can help you with your healthy lives and happy smiles.
  • Office Policy

    • Please help us to maintain the operation of our office so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you. Therefore, at least 24 hours' notice must be given if cancellation is absolutely necessary. Otherwise, it may be necessary to charge for the time lost.
    • This office bases its fees on the current British Columbia Dental Association General Practitioner's Fee Guide. However, if a particular procedure requires a significantly longer time than usual, where exceptional effort or skill is required, or unusual complications are present, a higher fee may be charged.
    • Service is to be paid for at each visit as they are performed unless prior arrangements have been approved.
    • There will be a 1.5% administration fee per month on all accounts over 30 days old.
    • Accounts over 90 days old will be sent to a collection agency.
    • If you authorize us to do so, this office is willing to accept direct payment from your dental insurance plan for services while your plan covers and is not based on the assumption that the insurance plan will pay the full cost of your treatment. You must pay your portion for the dental service according to your insurance policy.
    • To help our staff to concentrate more on your safety in the office while pandemic goes on and after it ends, you may be asked to pay all treatment fees on the date of the service, and the insurance company will reimburse you later. We can submit the claim to your insurance for you. Thus, there is nothing you need to do.
    • You are responsible for providing the necessary information in order for us to directly bill your insurance plan as well as informing us of any changes in this information.
    • If your dental plan does not cover the full cost of your treatment, you will be responsible for any difference between the amount paid by your plan and the amount charged. Your portion is then due and payable on the day of your appointment.
  • I have read and fully understand the above office policy statements. I consent to the terms.
  • Patient Rights and Consent

  • I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I have the opportunity to ask any questions and receive answers regarding this Medical/Dental history and I consent to my physician being contacted if necessary. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
  • I authorize this office to consult with or transfer my dental records to/from a medical doctor, specialist or other dentists if necessary or requested
  • I authorized the dentist and his or her qualified staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I understand that refusal to do may result in compromised treatment.
  • I authorize the dentist to perform any or all forms of treatment, medication, and therapy that may be indicated and consent to the use of local anesthetic agents.
  • As a patient, I understand that I have the right to be advised of the benefits, options, risks, and potential complications of any dental procedure, ask questions and receive complete answers regarding my oral health, and make an informed decision to accept or decline recommended treatment.
  • I agree that responsibility for payment of dental services by this office for myself or my dependents is mine (whether or not paid by insurance) and payable at the time services are rendered unless other financial arrangements have been made.
  • Signature

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.
Smile Well Dental Clinic conveniently located near to Capilano Mall in North Vancouver.
For patients of all ages, we are a dedicating dental team of professional and friendly staff that can meet all your needs in a safe and relaxing environment.

  • Address
    Suite #202, 814 15th St West
    North Vancouver, BC V7P1M6
  • Phone
    778-340-2897
  • Fax
    778-340-3373
  • Email
    [email protected]
  • Business Hours
    Mon. - Fri. 09:30 - 19:00
    Sat. 09:30 - 17:00
    Sunday/Statuary Holiday Closed

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Smile Well Dental
Copyright © 2018 Smile Well Dental | Designed By Green Apple Solutions

mail:[email protected]
tel: 778-340-2897

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