Patient Questionnaire
Please fill out the form and it will be email to us automatically when you press "submit".
First Name:

Last Name:

Street Address:

Mail Address:

City:

Province: (2 letter abbreviation, capitalised)

Postal Code: A9A 9A9 format

Phone: 999-999-9999 format

Alternative Phone: 999-999-9999 format

Email:


1. Are you new to the city of Brandon?
YES NO

2. How did you find out about Princess Dental?


3. Do you have immediate family members needing routine dental care?
YES NO       How many adults and children?

4. What was the date of last routine dental exam and professional cleaning?

Do you have immediate concerns?


5. Are you familiar with our "Payment Policy?" [ READ HERE ]
YES

6. Have you read our "Mission Statement"? [ Right side of page >> ]
YES

         
Please press "SUBMIT" - once, to send email questionnaire.
We will not share your information with any other business or enterprise.

READ MORE...
Payment Policies
Dental Insurance


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INTRODUCING

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MISSION STATEMENT

"Our whole reason to be….is the patient! Our goal is to provide the highest quality dental care based on prevention and what is best for the patient. In order to achieve this goal, we need each patient to have their own personally – designed re-care system. It is only through such a system that we can achieve optimum dental health and maintenance."

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©2009 Princess Dental Center. All Rights Reserved
smiles@inetlinkwireless.ca 		1202 Princess Avenue, Brandon, MB R7A 0R3
727-0440 or 1-866-378-6684 fax: (204) 725-3653
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