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Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Menu
Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Book Now
Ortho Intake Form
"
*
" indicates required fields
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- Personal Information
33%
Name
*
First Name
Last Name
Email
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Home Phone
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Cell Phone
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Are you over the age of 18?
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Parent/Guardian Name
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First
Last
Address
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Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Gender
*
Male
Female
Other
How did you hear about us?
*
Google Ads
Google Maps/Google Search
Billboard Signs
I Live Nearby
Referred By Friend
Social (Facebook, Instagram & Youtube)
How long have you been considering getting orthodontics?
*
0 to 3 Months
3 Months to 1 Year
1 Year to 2 Years
2 Year to 3 Years
3+ Years
Is this your 1st orthodontic consultation?
*
Yes
No
Do you have Dental Insurance?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
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Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Do you have a second Insurance Provider?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
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Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Consent
*
I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize Dental Now Panorama to preform any necessary dental services that I may need.
Patient/Parent & Guardian Signature
*
Dentistry Made Simple.
Thanks For Filling Out Our Form.