Appointment – Formulaires

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IMPORTANT NOTICE*

This form is intended exclusively for new patients seeking an initial orthodontic consultation. Please note that we do not provide care for retention appliances (lingual wire or retainer trays) when the initial treatment was not completed at our clinic. If you were treated at our clinic, we invite you to contact our team directly by phone at (450) 378-2365.

I understand

PLEASE NOTE*

Please note that we are not registered with the Canadian Dental Care Plan.

I understand

Patient information

First Name and Last Name*

Gender*

Age*

Date of birth*

Language*

Complete Address*

Address Apartment City Province Postal Code

Email*

Phone*

First name and last name of the first parent*

(If the patient is under 18 years old)

First and last name of the second parent

(If the patient is under 18 years old)

Name of the person to contact to schedule an appointment*

Contact person's phone number*

Would you prefer to receive appointment confirmations by:

Text Message

Please specify the phone number for the text message:

Do you already have a file at our clinic with another member of your family?

Yes

If yes, please provide the patient's name:*

Specific information

First and last name of your dentist*

Reason(s) for the appointment*

Lack of space

Crowding

Treatment requiring jaw surgery

Impacted canine

Aesthetics

Recommended by the dentist

I would like a second opinion

Other

Additional information

Have you ever received orthodontic treatment?*

Yes

If so, what orthodontic treatment have you already received?*

Braces

Invisalign aligners

Expansion appliance

Other

If Other, please specify:*

Are you currently undergoing treatment with appliances in your mouth (braces, expansion devices, aligners (Invisalign)…)?*

Additional information*

Will the patient be living in the Granby area for the next 2 years (planned move for studies or work, planned trip of more than 6 months…)?*

How did you hear about the clinic?*

Dentist

Internet search

Clinique Poster

Friends/family

Other

Accuracy of information*

I certify that the information provided is accurate. I have been informed that if the patient’s primary residence is not located in the Granby region over the next two years, it is highly likely that no orthodontic treatment can be initiated and that consultation fees will remain payable.

I certify

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