New Dental Patient Questionnaire

Cosmetic and Neuromuscular Dentistry in The Comox Valley of BC

Welcome to our clinic and thank you for choosing us for your dental care. Dr Nasralla and his team are looking forward to meeting you.

We are happy to tell you a little bit about our office. We believe that our patients are the most valuable part of this practice, and it is our mission to make every dental visit a pleasant experience. We offer refreshments and goodies in our reception area as well as a comfort menu including mp3 players, television, massage pad, warm towelettes and blankets.

Please do not be surprised to find that our fees may be higher than average practices. We would not be able to provide the level of care and service that we offer otherwise.

Our team knows the importance of running on time and we do our best to make sure you are in and out as quickly as possible while giving you the best quality dentistry, we ask for the same consideration from you with regards to arriving to your appointments on time. We appreciate feedback and suggestions so feel free to let us know how we can improve your dental experience.

We will be happy to submit claims to your dental plan if you have one, although we do require that you pay any portion not paid by insurance on the date of service for each appointment. We accept Visa, MasterCard, Interac, cash and cheques. Please know that we require 2 business days notice for cancellations or a fee will be levied.

If you have any questions before we see you for your appointment please feel free to call.

Yours truly,

Dr. Nasralla and Team

Patient Questionnaire

Date of Birth:

How did you hear about our office?:

Dental History

How long since your last dental exam?:

What was done at the time?:

Are you having any discomfort at this time?:

Yes

If yes, please specify:

Have you ever been given local anesthetic (freezing)?:

Yes

Have you ever been given general anesthetic?:

Yes

Have you had any complications with either?:

Yes

Are you aware of any swelling or lumps in your mouth?:

Yes

Are you eager to keep your natural teeth?:

Yes

Are you interested in the current trends of cosmetic dentistry?:

Yes

Are you satisfied with the appearance of your teeth and smile?:

Yes

If no, describe what you would like changed:

How healthy do you want your mouth to be?:

Don’t really care

Average

Best it can be

Should you need treatment, at what point should we address it?:

When tooth hurts/breaks

When it gets worse

When something isn’t ideal

What quality of dentistry do you want us to recommend?:

Medical History

Name of your Physician:

Date of last physical:

Are you currently in good health?:

Yes

Have you ever been told you need to take antibiotics before a dental appointment?:

Yes

Are you presently under the care of your physician?:

Yes

If yes, why?:

Are you presently taking any pills, drugs or medications?:

Yes

If yes, which ones and for how long?:

Are you presently taking, or have ever taken any Bisphosphonates?:

Yes

If yes, which one(s) and for what reason?:

Do you have any drug allergies?:

Yes

If yes, which drugs?:

Do you have any other allergies?:

Yes

If yes, which ones?:

Do you smoke?:

Yes

If yes, how many per day?:

Are you pregnant?:

Yes

If yes, how far along?:

Have you had any injury to your jaw or to your face?:

Yes

Have you been hospitalized in the past?:

Yes

If yes, for how long?:

Have you had any surgery in the past?:

Yes

If yes, what type of surgery?:

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New Dental Patient Questionnaire

Welcome to our clinic and thank you for choosing us for your dental care. Dr Nasralla and his team are looking forward to meeting you.