Let's Get Started
Please fill in this short questionnaire to get started!
How can we help your child?
Treat alignment issues
Preventive Checkup
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Alright! Let’s see how we can help. What alignment issues are you trying to address? (select any that applies)
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Where are you in your research on getting braces?
I’ve just started my research
I want to speak with a specialist on options and cost for braces
I’m not sure what is best for my situation!
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Our orthodontist can definitely help. Would you like your consultation at the clinic, or through a video conference call?
At the Vancouver clinic - 182 East 15th Ave
At the Surrey clinic - 7388-137th Street, Suite 3
Virtual appointment by video conference call
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How did you hear about PacificWest?
Dentist Referral
Google
Facebook
Word of mouth / friend / family
Other
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Your Contact Info
Alright! We’re all set. Please leave your contact information below. We will send you more information and contact you to set up a free consultation to find the best treatment option for you.
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred day / time of appointment
*
Name of dentist who referred you
*
Any notes or comments for us
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