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21st Century Dental Centre

Contact 21st Century Dental Centre

Call or email us to schedule a visit or inquire about our services. To learn more about 21st Century Dental Centre and our services — which include Invisalign, oral sedation, and family dentistry — or to schedule an appointment, please fill out our contact form or call us at 604-543-2600.

Contact Us

21st Century Dental Centre

139-12101 72nd Avenue

Surrey, British Columbia V3W 2M1

Phone: 604-543-2600
Fax: 604-543-2603
Email: 21dental@shawbiz.ca

Office Hours

Monday
11:00 AM - 07:00 PM
Tuesday
09:00 AM - 05:00 PM
Wednesday
09:00 AM - 05:00 PM
Thursday
11:00 AM - 07:00 PM
Friday
Closed
Saturday
09:00 AM - 05:00 PM
Sunday
Closed

Note: We are open two Saturdays per month. Please call to schedule an appointment!

Send Us a Message

Feel free to send us your questions and we’ll get back to you as soon as possible.

Name*

Phone

Email*

What is the best time for us to call you?

Service Required

Comments/Questions

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New Patient Form

We are accepting new patients. Fill the new patient form below and we’ll get back to you shortly.

Patient Information

Name:

(First)

(Last)

Birthdate:

Home Phone:

Cell Phone:

E-mail:

Address:

City:

Postal Code:

Sex:

Care Card #:

Whom may we thank for referring you to us?

Another office:

Friend/family:

Would you like appointment reminders sent to your phone by text or email?

Current employer and occupation?

Person responsible for this account (if the patient is a child)?

Relationship to the patient?

Birthdate?

Currently a patient in our office?

Insurance Information

Name of Insured:

Relation to Patient:

Birthdate:

Employer:

Insurance Company:

Group #:

ID#:

Have you used this plan this benefit year?

Additional Insurance Information

Name of Insured:

Relation to Patient:

Birthdate:

Employer:

Insurance Company:

Group #:

ID#:

Have you used this plan this benefit year?

Dental History

Reason for today’s visit:

Date of last dental care:

Have you had orthodontic treatment?

If yes, are you happy with the results?

Are you nervous during dental treatment?

Is there anything about the appearance of your teeth you would like to change?

If yes, please explain?

Medical History

Physician’s Name:

Phone Number:

Specialist Name:

Phone Number:

Have you had any serious illnesses/operations?

If yes, describe:

Have you ever been told if you require medication before dental appointments?

Are you allergic to penicillin?

Women only – Are you pregnant or nursing?

List medication you are currently taking:

Allergies:

Check if you have or have had any of the following:

Authorization and Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I also understand it is my responsibility to inform the office of any changes to my contact information or any changes in my dental insurance. It has been explained to me that although the staff at Dr. Parveen Atwal’s office will bill my insurance company directly when possible, any balances not paid by my insurance are my responsibility. I also consent to my personal physician being contacted if necessary.

Signature of patient, parent, guardian or personal representative:

Upload File

Print name of patient, parent, guardian or personal representative:

Date:

Relationship to patient:

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new-patients-form

Patient Update Form

Name:

Birthdate:

Home Phone:

Cell Phone:

E-mail:

Address:

City:

Postal Code:

Sex:

Care Card #

Would you like appointment reminders sent to your phone by text or email?

Physician’s Name:

Phone Number:

Specialist Name:

Phone Number:

Have you had any serious illnesses/operations? If yes, describe:

Have you ever been told if you require medication before dental appointments?

Are you allergic to penicillin?

Women Only – Are you pregnant or nursing?

List medication you are currently taking:

Allergies:

Check if you have or have had any of the following:

Authorization and Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I also understand it is my responsibility to inform the office of any changes to my contact information or any changes in my dental insurance. It has been explained to me that although the staff at 21st Century Dental Centre will bill my insurance company directly when possible, any balances not paid by my insurance are my responsibility.

I also consent to my personal physician being contacted if necessary.

Signature of patient, parent, guardian or personal representative:

Upload File

Print name of patient, parent, guardian or personal representative:

Date:

Relationship to patient:

update

COVID-19 Policy 

Our Safety Protocols

At 21st Century Dental Centre, we have changed some of our office protocols to help keep everyone safe.

  • * Upon arrival during your appointment, you will be asked to read and sign a COVID-19 screening/waiver.
  • * We ask that you please not arrive more than 10 minutes prior to your scheduled appointment time.
  • * Once you reach the office, you will be asked to sanitize your hands with the dispenser located nearest the front entrance.
  • * Please ensure you wear a mask. If you have forgotten one, we can supply you with one.
  • * We have installed a plexiglass barrier at the front desk
  • * There are 4 air purifiers located in the office.
  • * You will be temperature checked prior to entering the clinical area for treatment.
  • * Increased sanitization of the reception area/waiting room and washroom.
  • * Our team members are screened every morning prior to their shift.
  • * Staff PPE has been increased during clinical appointments, and masks are mandatory throughout the day.
  • * Contactless payment.

COVID-19 Waiver 

policy
waiver

Directions to our Surrey dental practice.

Cancellation Policy and Insurance Policies

Cancellation Policy

We have reserved your dental appointment especially for you. Please provide us with two business days' notice to cancel or reschedule this appointment to avoid a fee. Please note, we are closed every Friday.

Insurance Policies

We happily accept most insurance and direct bills. Please note that if there are fees not covered by insurance, you are responsible for this payment. (For example, if your insurance is 80%, you will be liable to pay the remaining 20%.)

 

It is possible that you may be referred to a specialist or have used your benefits at another office. Please notify our administrators if this is the case for us to help you keep track of the insurance limits used in the year. 

 

Predeterminations or authorizations: most insurance companies will not send a copy to the dental office due to the Privacy Act. Please forward these to the dental office at least one week before your dental appointment for the administrators to accurately quote your costs. 

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