Patient Intake Form - Smile Well Dental

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North Vancouver: 778-340-2897 Surrey: 778-877-3493 Surrey: 778-877-3493 North Vancouver: 778-340-2897North Vancouver: 778-340-2897

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Smile Well Dental

North Vancouver Dental Clinic

Home
About Us
Dental Services
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Contact Us
Book a visit
- Patient Intake Form
- Referral Form

Surrey: 778-877-3493

Home
About Us
Dental Services
Gallery
Blog
Contact Us
Book a visit
- Patient Intake Form
- Referral 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.
Office Location*
Personal Information
Name*
Prefix First Last
Birthday - mm/dd/yyyy*
MM slash DD slash YYYY
Email
Sex*
- Male
- Female
- Prefer not to say
Address*
Address City ZIP / Postal Code
Home Phone
Work Phone
Cell Phone*
Person to contact in case of emergency*
Phone*
Name of family members who are patients at our office
How did you hear about our office?*
- Friend / Relative
- Google
- Newpaper / flyer
- SNS (Facebook, etc)
Whom may we thank for referring you?
Reason for Visit
What bothers you most? (chief complaint)*

Do you have dental insurance?*
- Yes
- No
Insurance Information
BC Care Card #*
If student, name of school & If full time, enter student ID#
Primary Insurance Company's Name*
Dependent Name*
Dependent Birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Policy holder's name*
Insurance plan(Contract) number*
Insurance ID(Certificate) number*
Policy holder's Birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Relationship to policy holder*
Do you have secondary dental insurance?*
- Yes
- No
Secondary Insurance
Secondary Insurance Company's Name*
Dependent Name*
Dependent Birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Policy holder's name*
Insurance plan(Contract) number*
Insurance ID(Certificate) number*
Policy holder's birthday (mm/dd/yyyy)*
MM slash DD slash YYYY
Relationship to policy holder*

Medical Information
Physician's Name
Phone#
1. Are you in good health?*
- Yes
- No
If no, please provide details:
2. When was the last time you had a medical examination?*
3. Are you presently receiving treatment for any illness? If yes, please provide details:*
- Yes
- No
If yes, please provide details:
4. Have you ever been hospitalized? If yes, please provide details:*
- Yes
- No
If yes, please provide details:
5. Do you have any heart or circulatory problems?*
- Yes
- No
Do you have a pacemaker?
- Yes
- No
6. Have you ever had rheumatic fever?*
- Yes
- No
If yes, when:
7. Have you ever been advised to take antibiotic pre-medication before dental treatment?*
- Yes
- No
8. Do you have allergies?*
- Yes
- No
If yes, please list:
9. Are you presently taking any kind of medication? If yes, please specify:*
- Yes
- No
List*
Drug Reason
10. Have you reacted to any kind of medicine or dental local anesthetic?*
- Yes
- No
If yes, please provide:
11. Female patients - Are you pregnant or think you may be pregnant?*
- Yes
- No
Breastfeeding?
- Yes
- No
12. Please indicate below(v) if you presently have or have ever had any of the following:*
- None
- AIDS/HIV
- Alcohol or chemical dependency
- Arthritis or Rheumatism
- Artificial joints or valves
- Asthma
- Blood transfusion
- Cancer/radiotherapy/chemotherapy
- Diabetes
- Eating disorders
- Epilepsy/seizures
- Fainting/dizzy spells
- Heart surgery / Prosthetic valves / stent
- High/low blood pressure
- Hyper/hypoglycemia
- Osteoporosis / Osteomalacia
- Kidney disease
- Liver disease (Hepatitis/Jaundice)
- Lung disease/chest pains
- Mental or nervous disorder
- Stomach ulcers
- Stroke
- Tuberculosis
- Venereal/communicable disease
13. Do you smoke?*
- Yes
- No
If yes, how much per day?*
15. Is there any additional information related to your health that has not been addressed above?

Dental History
When did you see a dentist last? And, where(clinic name, location)?*
How frequently do you go to a dental clinic?
- 6 month
- 1 year
When did you get teeth cleaned in a dental clinic last?*
Have you ever been educated about oral hygiene instructions?
- Yes
- No
Have you ever had any complications with local anesthetics?*
- Yes
- No
If yes, how?
Have you had abnormal bleeding after dental procedures before?*
- Yes
- No
If yes, by what procedure?
Do you feel some pain around jaw joints when you open your mouth wide?*
- Yes
- No
Do you easily gag during dental treatment?*
- Yes
- No
Do you feel any discomfort when you lie down on a dental chair?*
- Yes
- No
Do you have any difficulty in breathing during dental treatment?*
- Yes
- No
Please check if you had the following treatments in the past:*
- None
- Orthodontic treatments (braces, Invisalign)
- Periodontal (Gum) Surgery
- Tooth Extraction
- Implant Surgery
- Jaw joints (TMJ) treatment (Splints)
- Treatment due to facial/oral trauma
Daily Habit Assessment
How often do you brush your teeth per day?
Please enter a number from 0 to 10.
Do you use dental floss?
- Yes
- No
If any, do you use other hygiene tools?
Do you grind or clench your teeth?*
- Yes
- No
Do you habitually chew something like pencils, nails, lips, tongue?
- Yes
- No
Oral Discomfort Assessment
Do you usually feel your mouth dry?*
- Yes
- No
Do you have any sensitivity on your teeth (cold, hot, sweet, chew)?*
- Yes
- No
Do you have gum bleeding?*
- Yes
- No
Do you feel any discomfort on your jaw or cheeks when you get up in the morning?*
- Yes
- No
Do you hear any sound from jaw joints when you open and close your mouth?*
- Yes
- No
Do you have any difficulty in mouth opening or closing?*
- Yes
- No
Do you have any headache, neckache, or shoulder pain?*
- Yes
- No
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.
Do you want a consultation about your dietary habits or nutritional guides?*
- Yes
- No
Are you concerned with your bone health?*
- Yes
- No
Are you taking any dietary supplements to improve or maintain bone health?*
- Yes
- No
Do you want to change your smile by having dental treatments such as braces and veneers for cosmetic purposes?*
- Yes
- No
Are you interested in facial esthetics such as BOTOX injection?*
- Yes
- No

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.*
I agree
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 agree
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 agree
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 agree
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.*
I agree
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
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.*
I agree
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.
Disclosure of photos, x-rays, and models - I consent to the disclosure of photography, filming, recording, models, and x-rays of mine for the purpose of patient education, consultation, advertisement, and publication, provided that my identity is NOT revealed.*
- Yes
- No
Signature
Patient or guardian*
Date
MM slash DD slash YYYY
Name
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 (North Vancouver)
Fax
778-340-3373

Email
[email protected]
Business Hours
Mon. - Fri. 09:30am - 6:00pm
Sat. 09:30 - 4:00pm
Sunday and Holiday: Closed

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

mail (North Vancouver): [email protected]
tel: North Vancouver: 778-340-2897