Suite 307, 5687 Yew Street, Vancouver BC, V6M 3Y2

604 261 8890

Patient Personal Information



Parent 1
Parent 2
If responsible party is other than the patient’s parents
Current Dentist/Doctor
Dental Insurance Information 1
Dental Insurance Information 2
Medical History

(Patient had or has the following medical conditions:)

FOR CLEFT/ PALATE PATIENTS ONLY

Ethnic origin (please check All that apply)

Key

Asian

African-American

Caucasian/ European

East Indian

First Nations

Latin American

Unknown

Other

Father

Mother

Patient

Consent