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First Name**

Last Name**

Email*

Phone**

Date of birth**

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What Location Would You Like to Visit?*

Preferred Method of Communication

Preferred Doctor*

Preferred Consultation Time

Preferred Consultation Days (Scottsdale)

Wed

Thu

Fri

Sat

Preferred Consultation Days (Langley)

Thu

Fri

Sat

Preferred Consultation Days (Guildford)

Thu

Fri

Sat

Alternative Preferred Consultation Time

Alternative Preferred Consultation Days (Scottsdale)

Wed

Thu

Fri

Sat

Alternative Preferred Consultation Days (Guildford)

Thu

Fri

Sat

Alternative Preferred Consultation Days (Langley)

Thu

Fri

Sat

Based on your above preferences, we will provide two different date/time options, and confirm with you before finalizing your appointment.

Do you have orthodontic insurance?*

Yes

No

Name of Insurance Company*

Name of Policy Holder*

Policy Holder Date of Birth*

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Policy/Group/Plan Number*

Certificate/ID Number*

Dentist Name

Dental Office

Upload Photos

If you can submit your photos, that will help us determine your treatment plan before your visit! Photos are optional but recommended 🙂

Virtual Consultation 5

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Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 4 MB, Max. files: 6.

Primary Concern

Crowding

Spacing

Bite

Jaw

Retainer

Other

Have you worn braces or invisible aligners in the past?

Yes

No

Choose the option that best describes your biggest concern with your smile:

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Of the images below, which one best describes your teeth crowding?

mild, or no crowding

moderate

extreme

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Of the images below, which one best describes your teeth spacing?

mild, or no extra space

moderate

extreme

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Ready to Start Your Orthodontic Treatment?

Book an Orthodontic Consultation

GUILDFORD CLINIC

15127 100 Ave #405
Surrey, BC V3R 0N9

SCOTTSDALE CLINIC

604-593-5225
7192 120 St
Surrey, BC V3W 3M8

LANGLEY CLINIC

19971 64th Ave
Langley, BC V2Y 1G9

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Treatments
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Patients
About
Referral
Contact
Book Now