top of page
MO logo.jpg
Dr. Gina Ball
Certified Specialist in Orthodontics

T: 604 892 5969

F: 604 892 5969

info@mountainorthodontics.com

Patient Information
Sex at Birth:

Insurance Information

1.

2.

3.

Date of last exam and hygiene appointment:

Please list outstanding treatment needed:

Panoramic X-Ray available:
Bitewing X-Ray available:

PIease note that no data transmission over the internet can't be guaranteed to be 100% secure. As a resuIt, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk. If you wouId prefer to contact us by teIephone to compIete this screening questionnaire, pIease caII: 604 892 5969

Thanks for submitting!

Girl at the Dentist

Dentist Referral Form

bottom of page