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  • 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

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  • DENTAL INSURANCE & DENTAL SERVICE PAYMENT

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

     

    DENTAL INSURANCE

  • DENTAL HISTORY

  • MEDICAL HISTORY

  • CONSENT FOR TREATMENT

    This is to certify that I, the undersigned, consent 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.

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  • Authorize for the release of patient records

  • I, authorize the release of patient records to Dr. Margaret Webb Inc. from*.

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  • Dr. Margaret Webb

    Dr Jessica Traude

    #530-2184 West Broadway

    Vancouver, BC V6K 2E1

    604-733-9833

    reception@arbutusdental.com

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