Patient Application
Please complete the form below to be considered to become a patient with us.
Patient's Name
*
First Name
Last Name
Gender
Male
Female
Other
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Who was the patient referred by?
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
*
Will the patient have transportation to all appointments?
Yes
No
Can you confirm that without Triangle Smiles, the patient would not be able to receive Orthodontic Treatment?
*
Yes
No
Please sign below to verify your answer above
*
Clear
Does the patient currently have access to dental care?
*
Yes, they do.
No, they do not.
Please use the space below to let us know where the patient receives dental care. If the do not receive dental care please elaborate.
*
If the patient has access to dental care, when was the time they visited a dentist? (Rough estimate)
*
How and when did you learn about Triangle Smiles?
*
Please answer the following questions with the patient.
Please describe your child's oral hygiene.
*
How would you describe your desire for braces?
*
I really want to invest my time and energy into braces.
I have somewhat thought about investing my time and energy into braces.
I rarely have considered investing my time and energy into braces.
I only recently have started thinking about investing my time and energy into my braces.
How long have you been considering receiving orthodontic care?
*
For multiple years.
For multiple months.
For the past few weeks.
I have just recently started to consider braces.
Why would you like to receive braces?
*
Lastly, please provide any additional information about you so we can get to know you a little more.
Thank you for applying!
Our team will review your application promptly and inform you of our decision! We ask that you sign below verifying all information is accurate.
Signature
*
Clear
Submit
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