Please complete the following questionnaire as proper treatment requires that we become acquainted with each patients vital information. All questions answered within are strictly confidential. Please feel free to contact reception for clarification or help.

PERSONAL HISTORY

DENTAL INSURANCE & DENTAL SERVICE PAYMENT

Patient’s payment will be due in full at the time treatment is rendered. We will assist patients with reimbursement from their insurance. Please be aware that our fees may be higher than your dental plan may riemburse. If you have any questions or concerns regarding insurance please contact our office. 

APPOINTMENTS

To assist us with our daily scheduling we request that you give us 48 hours notice for appointment changes. Your appointment time is reserved for you and a fee for short cancellations and missed appointments may apply.

 

DENTAL INSURANCE

DENTAL HISTORY

MEDICAL HISTORY

Please check if you've have or had any of the following:

CONSENT FOR TREATMENT

This is to certify that I, the undersigned, concent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including use of local anaesthetic as indicated. I fully understand the office policy and I will assume responsibility for fees associated with those procedures performed.

Authorize for the release of patient records

Dr. Margaret Webb

Dr Jessica Traude

#530-2184 West Broadway

Vancouver, BC V6K 2E1

604-733-9833

reception@arbutusdental.com