Patient Forms | Save Time Online

Welcome to Whistler Dental

NEW PATIENT FORMS

Prior to your appointment, you can save time by completing our Online New Patient Form. Alternatively, you may download and print a PDF version to bring with you. We look forward to meeting you!

If you have any questions, please call our office and speak with one of our knowledgeable patient care coordinators at 604.932.3677.

[PDF] DOWNLOAD NEW PATIENT FORMS:

ADULT PATIENT FORM CHILD PATIENT FORM

Complete ahead of your appointment to save time

NEW PATIENT ONLINE FORM

Click here to complete a Children’s New Patient Form

New Patient Form

Step 1 of 5

Patient Contact Information
First Name * Required
Middle Name
Last Name * Required
Date of Birth * Required
Gender * Required
How did you hear about our office? * Required
If you selected other, please tell us how you found us (optional but appreciated):
Main Phone * Required
Work Phone
Cell Phone
Address * Required
Street Address Address Line 2 City Province / State Postal Code / ZIP Country
Email Address * Required
Preferred Contact Method
Emergency Contact Information
Name * Required
Relationship
Home Phone * Required
Work Phone * Required
Cell Phone * Required
Insurance Coverage - BC Residents Only
Some exclusions apply for dental specialist appointments.
Select your insurance if applicable:
- I have Primary Coverage
- I have Secondary Coverage
Primary Coverage
Primary Insurer Name Date of Birth MM/DD/YY Insurance Company Plan Number Subscriber ID
We will provide you all necessary forms and information you may require to submit to your secondary insurance on your own behalf.

Dental Benefits / Payment and Appointment Change Policy
- As a courtesy and convenience to you, Whistler Dental accepts dental insurance plans upon confirmation of your coverage and allowable treatment. Based on this information, we are able to provide you with estimates of treatment required to the best of our knowledge. If we cannot get confirmation of coverage and allowable treatment, patients are required to pay the FULL amount at the time of service.
- Your dental policy is a contract between you, your employer and your insurance company. Should your coverage terminate or change in any way, we can only be notified of this by YOU, the patient. If treatment is not paid by your dental plan, it is the SOLE responsibility of you, the patient, to cover ALL costs. If your insurance company denies treatment, Whistler Dental will not resubmit insurance claims on your behalf and will then become your responsibility.
- In order for us to accept your insurance plan, we will require a valid credit card to remain on file for any treatment that is not covered by your insurance company.
- We bill all treatment done on the day the service is rendered. If we have not received payment from your insurance plan within 30 days of services rendered, then this claim becomes your responsibility. Any portion of any claim submitted to your insurance company that is not paid in a timely manner, will become your responsibly and will be charged to your credit card automatically. Secondary insurance claims are the responsibility of the patient. If you require any assistants with your insurance please speak with one of our staff; we would be more than happy to help.
- Please be advised for specialist appointments we require full payment at time of service. As a courtesy we will be happy to help you submit your insurance claim.
- If you need to change or alter your appointment, please provide our office with a minimum of 48 hrs advance notice during business hours to avoid a possible cancellation fee. Please note that making changes to specialists appointments requires minimum 4 days notice or cancellation fees will be applied.
I hereby authorize my insurance benefits to be paid directly to the dentist. I am financially responsible for any balances due and authorize the dentist to release information for any claim. I certify that I have read the contents of this form, filled in completely and accurately to the best of my knowledge. I understand the change of appointment policy. * Required
- YES, I UNDERSTAND AND AGREE
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NEW PATIENT FORMS

NEW PATIENT ONLINE FORM

New Patient Form

Step 1 of 5

Patient Contact Information

Emergency Contact Information

Insurance Coverage - BC Residents Only

General Information

Dental Information

Medical History

Bite, Jaw Joint and Sleep History

Sleep Analysis

Dental Benefits / Payment and Appointment Change Policy

Our Services

Our Hours

Drug	Purpose