Patient First Name*
Patient Last Name*
Date of Birth*
Mother Day Number
Father Day Number
Name of Policy Holder
Birthdate of Policy Holder
Reason for Orthodontic Consultation?
Have you had prior orthodontic treatment or evaluation?
Did your dentist refer you to our office?
If not, whom may we thank for recommending us?
Are you presently in good health?
Do you have an artificial joint, heart valve replacement or vascular graft?
Have you had an illness, operation, or been hospitalized in the last 5 years?
Have you ever been told that you require antibiotics prior to dental treatment?
Do you see a dentist for regular preventive care?
Have you ever had, or currently have, any medical conditions?
List of medical conditions
Are you taking any medication or non-prescription supplement?
List of medication
Do you Smoke?
Align Ortho would like your permission to use images taken of your child to showcase our practice on our website and social media.
I grant full permission for photographs of me/my child to be used onlineI grant only anonymous teeth photographs of me/my child to be used onlineI DO NOT grant permission for photographs of me/my child to be used online
Dr. Scramstad is a GP Dentist Providing Orthodontics only.
I understand this and provide consent for examination of myself/ my child.
I have read and accepts the Align Ortho - Privacy Act Information
Parent Signature (If Patient is a Minor)
#10-1455 Harvey Avenue
Kelowna, BC V1Y 6E9, Canada
(Corner of Burtch Rd & Harvey Ave)
HOURS: Tuesday – Thursday / 7:00 am – 5:00 pm
© 2021 Align Ortho.