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New Patients

Welcome to Coquitlam Centre Dental Clinic, where you can get the dental care, treatment, and advice you need to maintain your oral health. Whether you and your family live in Tri-Cities, or the surrounding area, we provide the emergency dental and general dentistry services you need to maintain and enhance your smile. 


Fill out Our New Patient Forms

New Patient Intake Forms

This information will be considered confidential and is for our purposes only.

Patient’s Name *

Female
Male
Trans
Non-Binary

Home Address *

Yes
No
Cell Phone
Other
Email

EMERGENCY CONTACT

Emergency Contact Name *

FOR CHILDREN/PATIENT'S WITH SPECIAL NEEDS

Yes
No

HEALTH HISTORY

Leukemia
Heart disease
Psychiatric disorder
Low blood pressure
Respitory disease
Stroke
High blood pressure
Epilepsy/seizures
Heart attack
Bruise easily
Infective endocartitis
Cancer
Blood disorder
Hepatitis A
Diabetes
Hepatitis B
Radiation/chemotherapy
Hepatitis C
Arthritis
Awaiting teast results for HIV
Jaundice
Tested positive for HIV
Gastrointestinal disorder
Awaiting test results for AIDS
Prosthetic joints/heart valve
Tested positive for AIDS
Eating disorder
Asthma/COPD
Drug and/or alcohol dependancy
Liver disease
Pregnant
Kidney disease
Breastfeeding
None
Yes
No
Yes
No
Yes
No
Yes
No
None
Clenching
Grinding
Nail biting
Thumb sucking
Yes
No
Yes
No

Do you use other recreation drugs? *

Yes
No
Yes
No

Name of physician

Yes
No

Please list any medications and their dosages*

Signature*

Contact Details

Coquitlam Centre Dental Clinic

1244-2929 Barnet HWY

Coquitlam, BC V3B 5R5

Phone

604-464-1511

Email

info@coquitlamcentredental.com

Hours

Monday 08:00 AM - 05:00 PM

Tuesday 08:00 AM - 05:00 PM

Wednesday 08:00 AM - 05:00 PM

Thursday 08:00 AM - 07:00 PM

Friday 08:00 AM - 05:00 PM

Saturday 08:00 AM - 05:00 PM

Sunday 10:00 AM - 05:00 PM

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Schedule
Appointment