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:

Smile Elements Orthodontics

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

New Patient:
(403) 768-0760

Current Patient:
(403) 730-6400

[email protected]

HOURS OF OPERATION

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

Brace Yourself For No Braces

Smile Elements Orthodontics