Dr. Francis La Couvée · Dr. Simon Gooch · 250-752-7524

 

New Patient Form

Please introduce yourself and your history to our caring and dedicated staff of dental professionals.

Personal Information






 

 

Dental Health History

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Medical Health History

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Do you have, or have you had, any of the following?

We require 48 hours notice for appointment changes. There is a charge for missed appointments and short notice cancellations. The patient portion of fees is due at the time of service. We will accept direct assignment from your insurance company but if for any reason they reject the claim or do not pay the full amount, you remain financially responsible for the balance. Claims to insurance not paid within six weeks will be billed to the patient.

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