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New Patient Questionaire

Are you currently in good Health?

Are you presently taking any vitamins or medications? 
Do you have any known allergies? 

Do you smoke?


Have you ever been hospitalized, had any surgeries or any serious illnesses or conditions in the past?

Do you have, or have had, any of the following? Please check all that apply:

Are you presently taking, or have ever taken any Bisphosphonates?
If Yes, please name: 


Patient Dental Insurance

Dental insurance is an individual commodity. There are hundreds of insurance companies and each company has thousands of individual group plans each being different from the next. There is no possible way that a dental office can be aware of precise information about your dental plan due to the Privacy Act of British Columbia.
Dental offices are not directly connected to insurance companies. Due to the Privacy Act of British Columbia, dental plans cannot release information to the patient's dental office. We rely solely on our clients to provide us their plan information. Insurance companies will only send the policy holder the information required by the dental office to submit your claims or for sending pre-authorizations on your behalf.

Please be aware that there are some insurance companies that we will only deal with "Non-Assignment" and that there are some plans that are set up by the employer to be "Non-Assignment".


You, the patient will pay the full amount of your dental appointment after each visit and we will submit all the paperwork to have your dental plan reimburse you directly.

*This option is only offered if you are able to supply all necessary insurance information below.


You, the patient will pay the full amount of any patient portion of your dental appointment after each visit and we will submit all the paperwork to have the dental plan reimburse us directly.
In addition your will consent to authorize us to debit your credit card (which will be kept on file) for any balance owing that your dental plan declines to pay either in part or in whole.
*This option is only offered if you are able to supply all necessary insurance and credit card information below.


I, authorize Dr. P. S. Nasralla Inc. to keep my signature on file and to charge my credit card with any balances unpaid by my dental insurance for treatment that I have received.

I would also like all my patient balances to be automatically processed to my credit card of file.



Employees Name

Group/Policy #:
ID/Certificate #:




Financial Agreement


Would you like to have correspondence by email? (Appointment Reminders etc.)  

APPOINTMENTS: I am aware that appointment times have been reserved for me. If I am unable to keep my appointment I will allow 2 business days' notice to avoid a late cancellation or missed appointment fee of $100/hr.

PERMISSION TO TREAT: This to certify that I (the undersigned or guardian), consent to the performing of the dental and oral procedures to be necessary or advisable, including the use of local anaesthesia. I authorize the release of any records that are relevant to the processing and payment held by Dr P. S. Nasralla Inc., to any appropriate health professional licensing or regulatory body for the purpose of an administrative audit.

ESTIMATES: I am aware that any estimates given are based on Dr Nasralla's professional judgement, but always within a clear understanding that they are not a binding maximum or fixed fee quotation. The dental fees may be higher than our estimate because of unforeseen changes, events, delays that occur or circumstances that may arise which require us to perform additional services for you not originally anticipated or expected. Often, we cannot anticipate the ultimate complexity of the action at hand, nor the time and labour that will be required of us to handle it accordingly.

PERMISSION TO RELEASE X-RAY IMAGES & REPORTS: I authorize the release of x-ray images and/or dental reports to other dentists and/or specialists for second opinions and/or treatment.

X-RAY RELEASE: I authorize the release of x-ray images and any other necessary documents for the purposes of future dental treatment to the office of Dr. Phil Nasralla Inc.

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