placeholder Skip to content
New Patient Forms | Book An Appointment
(604) 266-8277
FacebookTwitterYouTubeInstagramEmail
Clear Advantage Dental & Orthodontic Clinic Logo Clear Advantage Dental & Orthodontic Clinic Logo
  • About
    • Meet The Doctor
    • Meet the Team
    • What Sets Us Apart
    • Our Blog
  • New Patients
    • Office Visits
    • Financial Information
    • Orthodontics Cost Calculator
    • Office Tour
    • ABO Certification
    • New Patient Forms
    • Covid19 Patient Form
  • General Dentistry
    • Cavities and Dental Fillings
    • Dental Bridges
    • Dental Crowns
    • Dental Hygiene
    • Root Canal Treatment
    • Teeth Grinding and Mouth Guards
    • Wisdom Teeth and Tooth Extraction
  • Cosmetic Dentistry
    • Teeth-Whitening Services
    • Dental Implants
    • Dental Veneers Vancouver
  • Orthodontics Vancouver
    • Invisalign® Vancouver
    • Types of Braces Vancouver
    • For Children
    • For Adults
    • Orthodontic FAQs
    • Life with Braces
    • Two-Phase Treatment
    • Common Treatments
    • Incognito™
    • Oral and Maxillofacial Surgery
    • Surgical Orthodontics
    • Acceledent® Aura Orthodontics
    • Retainer Instructions
    • First Aid
  • Neuromodulator Treatments
    • Botox® Vancouver
    • TMJ & Migraine Headache Treatments
  • Contact
    • Book Online
    • Oakridge Location
    • Granville St Downtown Location

New Patient Forms

New Patient FormsSpencer2022-01-18T15:08:23-08:00
Jump to:
  • Adult Patient Form
  • Child Patient Form
  • Teen Patient Form
  • New Adult Patient Form

  • New Child Patient Form

  • New Teen Patient Form

  • New Adult Patient Form

  • New Adult Patient Form

  • MM slash DD slash YYYY
  • This information greatly helps us.
  • Are you interested in Dental Financing or Payment Plan?
  • Dental Coverage

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Clear Advantage Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

    2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

    3. I have read this document in full and consent to the following financial agreement:

    4. I, authorize Clear Advantage Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
  • Person Responsible for Payment

    Info of person responsible for payment of account (if different from above)
  • MM slash DD slash YYYY
  • Medical History

  • Specific History

  • Dental History

  • Medications

  • I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
    *
  • We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
    *
  • This field is for validation purposes and should be left unchanged.
  • New Child Patient Form

  • New Child Patient Form

  • MM slash DD slash YYYY
  • Parent Information

  • MM slash DD slash YYYY
  • This information greatly helps us.
  • Are you interested in Dental Financing or Payment Plan?
  • Dental Coverage

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Clear Advantage Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

    2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

    3. I have read this document in full and consent to the following financial agreement:

    4. I, authorize Clear Advantage Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
  • Medical History

  • Specific History

  • Does your child have any of the following:
  • Dental History

  • Medications

  • I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
    *
  • We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
    *
  • This field is for validation purposes and should be left unchanged.
  • New Teen Patient Form

  • New Teen Patient Form

  • MM slash DD slash YYYY
  • Parent Information

  • MM slash DD slash YYYY
  • This information greatly helps us.
  • Are you interested in Dental Financing or Payment Plan?
  • Dental Coverage

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 1. A valid credit card will be required at your appointment and MUST remain on file. It is your responsibility to notify Clear Advantage Orthodontics of any change which affects your credit card account. - Expiry date, change of account number, etc.

    2. Your account must remain in “Good Standing” – any account with an outstanding or uncollected balance for more than 60 days will no longer be considered eligible for Direct Billing. You will then be responsible for full account balances and all fees must be paid in full at time of treatment for all future appointments. You will be notified in writing of the change to your account status if the privilege of Direct Billing has been revoked.

    3. I have read this document in full and consent to the following financial agreement:

    4. I, authorize Clear Advantage Orthodontics to keep my signature on file and charge my credit card for any outstanding balance after 30 days of service. I will be notified by phone or mail if this amount is more than $200. A receipt for this transaction will be mailed, along with a statement of my account. Any lack of adherence to these terms will result in a loss of this direct billing benefit.
  • Medical History

  • Specific History

  • Does your teen have any of the following:
  • Dental History

  • Medications

  • I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
    *
  • We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time.
    *
  • This field is for validation purposes and should be left unchanged.
Clear Advantage Dental & Orthodontic Clinic
Clear Advantage Dental & Orthodontic Clinic
650 West 41st Ave, Suite 315 South Tower
Vancouver, BC, Canada V5Z 2M9
604.266.8277
info@clearadvantageortho.com

Hours:
Monday - Friday 9:00am-5:00pm
Clear Advantage Dental & Orthodontic Clinic
464 Granville Street
Vancouver, BC, Canada V6C 1V4
604.266.8277
info@clearadvantageortho.com

Hours:
Wednesday – 12.00pm – 7.00pm
Thursday – 12.00pm – 8.00pm
Friday – 12.00pm – 6.00pm
Saturday – 10.00am – 6.00pm
Sunday – 10.00am – 6.00pm
  • Site Map
  • Contact Us
American Association of OrthodonticsInvisalignCAO / ACO
© 2023 Clear Advantage Dental & Orthodontic Clinic | All Rights Reserved
FacebookTwitterYouTubeInstagramEmail