Book a Free Ortho Consultation | SmileSquad Childrens' Dentistry & Ortho

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Orthodontics
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Lip + Tongue Ties
The Squad
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Locations
- Bathurst + St Clair
- Leaside

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Whom is this visit for? *

Child/Teen

Adult

Contact Info

PATIENT CONTACT INFO

First Name *

Last Name *

Email Address *

Phone Number *

I prefer to be contacted via: *

Email

Text

Phone

Contact Info

PARENT CONTACT INFO

Parent First Name *

Parent Last Name *

Email Address *

Phone Number *

I prefer to be contacted via: *

Email

Text

Phone

Booking Info

Existing patient? *

Existing Patient

New Patient

Reason for visit, or other details *

Do you have dental insurance? *

Yes

No

Name of insurance provider: *

Your Child's Info

How many children are you bringing for assessment? *

One

Two

Three

Four

I am bringing one child

I am bringing two children

I am bringing three children

I am bringing four children

Child (1)

Child's First Name *

Child's Last Name *

Date of Birth *

Existing Patient? *

Existing Patient

New Patient

Do you have dental insurance? *

Yes

No

Name of insurance provider: *

Reason for visit, or other details *

Child (2)

Child's First Name *

Date of Birth *

Existing Smile Squad Kids Dental patient? *

Existing Patient

New Patient

Do you have dental insurance? *

Yes

No

Name of insurance provider: *

Reason For Visit

Same as Child 1? *

Yes

No

If no, please provide reason for visit or other details

Child (3)

Child's First Name *

Date of Birth *

Existing Smile Squad Kids Dental patient? *

Existing Patient

New Patient

Do you have dental insurance? *

Yes

No

Name of insurance provider: *

Reason For Visit

Same as Child 1? *

Yes

No

If no, please provide reason for visit or other details

Child (4)

Child's First Name *

Date of Birth *

Existing Smile Squad Kids Dental patient? *

Existing Patient

New Patient

Do you have dental insurance? *

Yes

No

Name of insurance provider: *

Reason For Visit

Same as Child 1? *

Yes

No

If no, please provide reason for visit or other details

Your Requested Date

Preferred Date (this is a request only) *

Time *

This is only a request. You will be contacted via your preferred method for confirmation. *

Yes, I understand.

Comments

If you are human, leave this field blank.

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The Squad
Locations
- Bathurst + St Clair
- Leaside
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FAQS