(250) 374-7227
info@drmarnie.com
Suite 402-275 Lansdowne St.
Kamloops, BC, V2C 6J3
Toll Free: 1(877) 994-7227
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New Patient Form
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How did you hear about Dr. Marnie?
Email:
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I am interested in:
Botox Cosmetic
Invisalign - invisible braces
Zoom Tooth Whitening
Cosmetic smile makeover
Sleep Dentistry for nervous individuals
Periodontal Disease or Laser Treatment
Bad Breath or Halitosis
TMJ or TMD or Headaches
Grinding, Clenching or Bruxism
Removing mercury fillings
Dental Implants
Selected any condition for which you have ever been treated:
Diabetes
Rheumatic Fever
Epilepsy
Hypertension
Kidney disease
Cardiovascular Disease
Respiratory Disease
Hepatitis or HIV
Prolonged Bleeding
Cold sores
Canker sores
Local anesthetic sensitivity
Family Physician:
Do you have any drug allergies?
Have you had any serious past illnesses or surgeries:
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No
Do you take any current medications including aspirin, birth control, herbal medication:
Yes
No
If yes, what?:
Are they currently being treated for any conditions not listed?
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No
Do you smoke?
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Are you currently pregnant or breast feeding?
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We want to be here for you. If there were one thing we could do to help meet your needs what would that be?
Type the characters you see in the picture below
New Patient Experience
High Tech Dentistry
Cosmetic Smile Makeover
Sleep Dentistry / Sedation
Hygiene / Periodontal Disease
Removing Mercury Fillings
Zoom Whitening
Botox Cosmetic ®
TMJ / TMD Treatment
Lasers - No Needles
Neuromuscular Dentistry
Digital Xrays / Less Radiation
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