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Your Calgary Spark™ & Invisalign^® Clear Aligners Provider

5010 Richard Rd SW #340 Calgary AB T3E 6L1 CA

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5010 Richard Rd SW #340 Calgary AB T3E 6L1 CA

Refer a Patient

Your Calgary Spark™ & Invisalign^® Clear Aligners Provider

Call (403) 282-7878
Book Consultation

About
Services
Children
Teens
Adults
Patients
Contact

Search

New Patient Form

Now that you've booked your first appointment at Surrideo Orthodontics, you will need to fill out the new patient form below to get started.

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone (Primary) *

Phone (Secondary)

Address *

City *

Postal Code *

Family Physician *

Family Dentist *

Does the patient have any relatives who have had treatment in this practice? *

Yes

No

Unsure

Does the patient have dental insurance that covers orthodontic treatment? *

Yes

No

Unsure

Parent / Guardian Information

If completing this form for a minor, please complete parent / guardian information below.

First Name *

Last Name *

Relationship to Patient *

Phone (If different from above)

Address (If different from above)

Medical History

Have you previously consulted another orthodontist? *

Yes

No

Have you had any previous orthodontic treatment? *

Yes

No

Are you currently taking any medication? *

Yes

No

If yes, please list *

Do you have any allergies? *

Yes

No

Do you have a history of any serious illness? *

Yes

No

Have you had injuries to the head? *

Yes

No

Have you been informed of any missing or extra teeth? *

Yes

No

Do you have a history of any of the following? (Check all that apply) *

Anemia

Bone Disorders

Diabetes

Epilepsy

Fainting or Dizziness

Heart Trouble

Gland or Endocrine Problems

Rheumatic Fever

Nervous Disorders

Congenital Abnormalities

Emotional Disorders

Tuberculosis

Liver Problems

Blood Disorders

Hepatitis

HIV Infection

Prolonged Bleeding

Kidney Problems

Frequent Colds

Asthma

Ear Infections

Chronic Nasal Obstruction

Mouthbreathing

Adenoid Problems

Tonsillitis

Tongue thrusting

Tooth grinding or clenching

Headaches (frequent)

Muscular soreness around head and neck

Jaw joint clicking of popping

Thumbsucking

Finger sucking

Lip biting or sucking

N/A

Have you received treatment for any of the above problems? *

Yes

No

Have your tonsils been removed? *

Yes

No

Unsure

Have your adenoids been removed? *

Yes

No

Unsure

Dental History

Do you have regular dental checkups? *

Yes

No

Date of Last Checkup *

How often do you brush your teeth? *

After every meal

Once per day

Twice per day

Do you floss? *

Yes

No

Reason for seeking orthodontic consultation? *

I hereby acknowledge that the health history provided is correct. *

Yes my information is correct

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No Referral Needed

At Surrideo Orthodontics, you never need a referral. Simply contact our Calgary orthodontic clinic to book a complimentary consultation and start your journey to a straighter, healthier smile.

Book Consultation Call (403) 282-7878

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Location

5010 Richard Rd SW #340 Calgary AB T3E 6L1 CA

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Hours

Monday:07:45 am - 04:30 pm
Tuesday:07:45 am - 04:30 pm
Wednesday:07:45 am - 04:30 pm
Thursday:07:45 am - 04:30 pm
Friday:07:45 am - 04:30 pm
Saturday:Closed
Sunday:Closed

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Corus Orthodontists. Managed with Tymbrel.