Intake Form | Smile Elements Orthodontics

Smile Elements Orthodontics

Prior to a consultation, all patients are required to fill out a form. We offer a digital form so patients can fill out the form before their appointment allowing for a smoother consultation process. Please assist us to provide you with the optimum care by answering every applicable question on this form. All information on this form will be kept confidential. Thank you.

First Name:

Last Name:

Middle Name:

Preferred Name:

Birthdate:

Sex:

Identifies As:

Home Address:

City:

Province:

Postal Code:

Home Phone:

Work:

Cellular:

Other:

Email:

Relationship to Patient:

First Name:

Last Name:

Middle Name:

Home Address (If Different Than Above):

City:

Province:

Postal Code:

Email:

Home Phone:

Work:

Cellular:

Other:

Relationship to Patient:

First Name:

Last Name:

Middle Name:

Home Address (If Different Than Above):

City:

Province:

Postal Code:

Email:

Home Phone:

Work:

Cellular:

Other:

Primary Insurance Company:

Employer Name:

Subscriber Name (Policy Holder):

Birthdate:

Group (Policy) Number:

Division Number:

Certificate Number:

Secondary Insurance Company:

Employer Name:

Subscriber Name (Policy Holder):

Group (Policy) Number:

Division Number:

Certificate Number:

Patient's Primary Dentist:

Your privacy. Smile Elements Orthodontics collects the information on this form to register you as a patient, assess your orthodontic care, and arrange billing with you or your insurer. We collect and protect your health information under Alberta's Health Information Act. Only our clinical and administrative team can see it, and we share it only with people involved in your care, your insurer when you ask us to, or as the law requires. Questions about your information go to our privacy contact at info@smileelements.ca or (403) 730-6400. Read our Privacy Policy.

Privacy consent

I have read this notice, and I am the patient or the patient's parent or guardian.

Smile Elements Orthodontics

#250, 15 Royal Vista Place NW
Calgary, AB T3R 0P3

New Patient:
(403) 730-6400

Current Patient:
(403) 730-6400

info@smileelements.ca

HOURS OF OPERATION

Monday: 8:30-15:30
Tuesday: 9:30-17:00
Wednesday: 9:30-17:00
Thursday: 7:30-15:30
Friday: 7:30-15:30

Monday:	8:30 AM – 3:30 PM
Tuesday:	9:30 AM – 5 PM
Wednesday:	9:30 AM – 5 PM
Thursday:	7:30 AM – 3:30 PM
Friday:	7:30 AM – 3:30 PM
Saturday:	CLOSED
Sunday:	CLOSED