Dr Terry Grover - Practitioner of General Medicine
About Dr Terry Grover
Kelowna Dental Services
Handy Dental Resources
Frequently Asked Dental Questions
Contact Dr Terry Grover's Office

Office Location
205 - 1626 Richter St.
Kelowna, BC
V1Y 2M3

T: 250-862-3070
F: 250-862-5011

 

General Information Form

PERSONAL INFORMATION:
Name * A value is required.
Preferred Name
Birthdate * A value is required.
Referred By
Address * A value is required.
City * A value is required.
Province *
Postal Code *
Email * A value is required.Invalid format.
Phone * A value is required.
Business
DENTAL PLAN COVERAGE: PERSONAL
Employed By
Position
SIN #
Name of Dental Insurance Co
Group #
Cert/ID #
Date Effective
Employer's Signature Required
Deductible
Coverage
Basic %
Major %
Ortho %
Financial Limit
DENTAL PLAN COVERAGE: SPOUSAL
Name of Spouse
Birthdate
Business Phone
Employed By
Position
Name of Dental Insurance Co.
Patient Dependant #
Date Effective
Employers Signature Required
Deductible
Group #
Cert/ID #
SIN #
Coverage
Basic %
Major %
Ortho %
Financial Limit
MEDICAL INFORMATION:
Physician's Name *
Location *
Dr Phone #
When was your last complete physical exam?
Are you being treated by a physician at this time?
Are you taking any pills, drugs, medications or herbal supplements?
Do you have any drug allergies?
Have you been hospitalized or had any surgery in the past (5) years?
Do You Have a History of:
(select all that apply - hold down the control key for multiple selections)

Have you ever had any traumas or injuries to the head and neck?
Are you pregnant or could you possibly be pregnant?
Have you ever been advised to take medication such as antibiotics prior to your dental appointments?
Do you have any other significant illnesses?
DENTAL HISTORY
Previous Dentist’s Name
Location
Last Dental Visit (MM/YY)
Last Dental X-Rays (MM/YY)
Last Dental Hygiene Visit (MM/YY)
Are you anxious at dental appointments?
Do you have a problem with the local anaesthetic?
Do You Have a History of:
(select all that apply - hold control key for multiple selections)
GENERAL INFORMATION
Are you on a regular dental hygiene maintenance program?
Have you had any bad experiences at the dentist?
Have you been satisfied with your past dentistry?
Have you ever gone 5 years without needing any dentistry?
How would you rate your present dental health?
Why would you rate yourself that way?
How do you feel about the appearance of your teeth?
If you could change one thing about your mouth, what would it be?
How can we help you?
 

 
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