Patient Registration Form

Skip to content

YOUR OTTAWA INVISALIGN PROVIDER®

613-247-7070

Request Appointment

About Us
Services
New Patients
Reviews
Blog
Contact

About Us
Services
New Patients
Reviews
Blog
Contact

About Us
Services
New Patients
Reviews
Blog
Contact

Patient Registration Form

"*" indicates required fields

Patient Information

Salutation*

First Name*

Last Name*

Date of Birth*

DD slash MM slash YYYY

Registering for a child?*

Yes

No

Person responsible for account*

Other parental consent required*

Yes

No

Mother’s name*

Business Tel

Father’s name*

Business Tel

Contact Information

Email*

Home Phone

Cell Phone*

Work Phone

Address*

Street Address City Province Postal Code

In case of emergency, please notify:

Name*

Relation*

Home Phone

Cell Phone*

Work Phone

Contact Options

I prefer appointment reminders by*

Phone

SMS (TEXT)

Email

Whom may we thank for referring you?

Google

Facebook

Instagram

Tiktok

Referred By

Patient/Friend Name

Are any other members of your family patients at our practice?*

Yes

No

Please list all family members*

Insurance Information*

Yes, insurance applies to me

No, insurance does not apply to me

Please complete the following if you have dental insurance

Name of insured/subscriber*

Date of Birth*

DD slash MM slash YYYY

Patient's relationship to subscriber*

Self

Spouse

Child

Place of Employment*

Insurance Company*

Policy/Group #*

Certificate/ID #*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*

Yes

Does secondary insurance apply to me?*

Yes, insurance applies to me

No, insurance does not apply to me

Upload Photo of Insurance Card

Drop files here or

Max. file size: 8 MB, Max. files: 100.

Dental History

Do you have any specific dental concerns? Please list:

When was your last dental appointment?*

DD slash MM slash YYYY

How often do you see the dentist?*

Not Applicable

Every 3 months

Every 4 months

Every 6 months

Only when something is bothering me

Is there anything about the appearance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Yes

No

Not Sure/Maybe

Do you feel uncomfortable or self-conscious about the appearance of your teeth?

Yes

No

Have you been disappointed with the appearance of previous dental work?

Yes

No

Please Explain

Privacy Policy*

By submitting this form, I agree to receive emails with related information and updates, and understand I can change my preferences at any time. See our Privacy Policy.

Resources

Home
About Us
Services
New Patients
Reviews
Contact

Home
About Us
Services
New Patients
Reviews
Contact

Contact Info

Hours

Monday	7am – 4pm
Tuesday	7am – 4pm
Wednesday	7am – 4pm
Thursday	7am – 4pm
Friday	8am – 2pm

Privacy Policy

XML Sitemap

Accessibility Statement

Facebook