Patient form

Patient Information

Full Name *

Preferred Name

Date of Birth *

Email *

Address *

City *

Postal Code *

Home Phone

Cell Phone *

Preferred Contact Method *

PhoneEmailText

Referral Information

Canadian Dental Insurance Information

Primary Policy Holder Name

Relationship to Patient

Insurance Company

Employer Name

Policy / Group Number

Certificate / ID Number

Do you have dual coverage?

YesNo

Secondary Insurance Company

Secondary Policy / Group Number

Secondary Certificate / ID Number

Smile Assessment Questionnaire

What concerns you most about your teeth or smile?

Have you noticed difficulty biting, chewing, or speaking?

Do you have jaw pain, clicking, or tension?

Are you satisfied with your smile?

What would you like to improve?

AlignmentSpacingBiteCrowding

How motivated are you to start orthodontic treatment?

VerySomewhatNot sure

Is there a special event motivating you to seek treatment?

I certify that the above information is true and complete to the best of my knowledge.

Thank you! Your submission has been received!

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New Patient Registration