Child Med HX Form

  • Child Form

    Welcome to our office. The following information will enable us to provide you an accurate evaluation of your orthodontic problem during your initial examination in our office. This information, which is important for our records and your health, is  confidential.

  • Date of Birth*
     - -
  • Sex*
  • Format: (000) 000-0000.

  • Family History

  • Patient lives with*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical History

  • General Health*
  • Are you pregnant or suspect you may be?*
  • If yes, what is the expected delivery date?
     - -
  • Have you been advised to take antibiotics before a dental appointment?*
  • Have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid or Zometa?*
  • Please check all that apply to you*
  • Are there any medical conditions we have not discussed that you feel we should be aware of?*

  • Smile Esthetics

  • When was the last dental check-up?
     - -

  • Dental History

  • Do you hear noises in your jaw joints?*
  • Do you experience pain in or about the ears, temples, or cheeks?*
  • Do you experience soreness, stiffness or fatigue of the muscles of the face?*
  • Do you experience difficulty, pain or both when chewing, talking, or using your jaws?*
  • Have you had any injuries to your head, neck, or jaw?*
  • Have any teeth been injured due to accidents to the mouth?*
  • Do any of the teeth ache?*
  • Have you received or been requested to receive speech correction?*
  • Have you ever had any type of thumb/finger sucking habit or tongue habit?*
  • Have you had other habits (lip biting, nail biting, etc.)?*
  • Do your gums bleed when you brush your teeth?*
  • Have you had any periodontal (gum) problems in the past?*
  • Have you ever had any previous orthodontic treatment (braces, Invisalign)?*
  • Are you being followed up by any other Dental Specialist?*
  • Do you smoke?*
  • Do you use e-cigarettes, vape or use a Juul?*
  • Has your Dentist ever recommended a night guard?*
  • Is there a family history of sleep apnea?*
  • How often do you brush your teeth?*
  • How often do you floss your teeth?*

  • Airway/Breathing Questionnaire

  • While sleeping, does your child… (Choose all that apply)*
  • Have you ever… (Choose all that apply)*
  • Does your child… (Choose all that apply)*
  • This child often… (Choose all that apply)*

  • I authorize Wilk & Wilk Orthodontics to use the phone number and email address provided above only for the purposes of maintaining correspondence concerning treatment, account balances, office events, educational information relating to orthodontics, appointment reminders, and other related practice communications.

  • Date*
     - -

  • We respect your privacy. We protect your information.


    PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION


    In an effort to respond to the privacy concerns of Canadians, the federal government enacted the Personal Information Protection and Electronic Documents Act (PIPEDA). Effective January 1, 2004, PIPEDA establishes principles for the collection, use and disclosure of personal information in Canada. Wilk & Wilk Orthodontics supports PIPEDA and the provincial privacy laws. We understand the importance of protecting your personal information and are committed to collecting, using and disclosing your personal information responsibly. As a result, Wilk & Wilk Orthodontics has implemented a Privacy Code, which may be reviewed at any time, and a Privacy Information Officer: Dr. Brian E. Wilk.

    All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us and are all trained in the appropriate uses and protection of your information.

    If you have any questions about how your privacy is protected in our office, please feel free to ask.

     

    How Our Office Collects, Uses and Discloses Patients’ Personal Information

    Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.

    This office will collect, use and disclose information about you for the following purposes:

    •  to deliver safe, efficient and high quality patient care
    •  to assess your health needs and risks
    •  to advise you of treatment options
    •  to enable us to contact you and maintain communication with you
    •  to offer and provide treatment, care and services in relationship to the oral  and maxillofacial complex and dental care generally
    •  to communicate with other treating health-care providers, including              specialists and general dentists who are the referring dentists and/or peripheral dentists
    •  to allow us to efficiently follow-up for treatment, care and billing
    •  for teaching and demonstrating purposes on an anonymous basis
    •  to complete and submit dental claims for third party adjudication and payment
    •  to comply with legal and regulatory requirements, including the delivery of  patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
    •  to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes
    •  to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
    •  to deliver your charts and records to the dentist’s insurance carrier to enable the  insurance company to assess liability
    •  to prepare materials for the Health Professions Appeal and Review Board (HPARB)
    •  to invoice for goods and services, process credit card payments and to collect unpaid accounts
    •  to assist this office to comply with all regulatory requirements
    •  to comply generally with the law

    Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defence of a legal issue.

    You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

     

    Patient Consent

    I have reviewed the above information that explains how Wilk & Wilk Orthodontics will use my personal information, and the steps your office is taking to protect my information.

    I know that your office has a Privacy Code that I can ask to see at any time, as well as a Privacy Information Officer.

    I agree that your office can collect, use and disclose personal information about the below patient as set out above in the information about the office’s privacy policies. I am also aware that if a new purpose arises for the use and/or disclosure of my child’s personal information, your office will seek my approval in advance.

  • Date*
     - -
  • Should be Empty: