TGO English Child - Acquaintance Form

1
Date* This field is required.
Date
Month
Day
Year
2
Full Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Dr.
Dre.
Prefix
First Name
Last Name
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
School* This field is required.
5
Which grade?* This field is required.
6
Home Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Mobile Phone Number* This field is required.
Please enter a valid phone number.
8
Do you have a dentist?* This field is required.
YESNO
9
Patient's Dentist* This field is required.
Dr.
Dr.
Dre.
Prefix
First Name
Last Name
10
My last dentist visit was:* This field is required.
In the last 6 months
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
11
Referred by
Internet
Social
Patient
Other
Please choose
Please list
12
Person responsible for account* This field is required.
First Name
Last Name
13
Parents / Guardians
Name
Name
14
Do you have an insurance plan that covers orthodontic treatment?* This field is required.
YESNO
15
Has the child ever been treated for any of the following:* This field is required.Please select all that apply.
Arthritis
Endocrine Problems
Digestive Disease
Bone Disorders
Diabetes
Liver Disease
Asthma
Blood Disorders
Jaundice/Hepatitis
Lung Disease
Cancer
Kidney Disease
Nervous Disorders
Heart Problems
Skin Problems
Epilepsy
Rheumatic Fever
Infectious Diseases
None
16
Do you have a family physician?* This field is required.
YESNO
17
Family Physician* This field is required.
Family Physician Name
Telephone Number
18
Is the child in good health* This field is required.
YESNO
19
Does the child have any history of major illnesses and/or operations?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Is the child taking any medications* This field is required.
YESNO
21
List any medications now being taken and provide reasons:
Huge
Large
Normal
Small
Ok
Ok
22
List any allergies or drug sensitivities?* This field is required.
YESNO
23
List any allergies or drug sensitivities:
Huge
Large
Normal
Small
Ok
Ok
24
Does the child have a tendency to get colds?* This field is required.
YESNO
25
Does the child have a tendency to get sore throats?* This field is required.
YESNO
26
Does the child have a tendency to get ear infections?* This field is required.
YESNO
27
Have tonsils and/or adenoids been removed?* This field is required.
YESNO
28
Has the child reached puberty?* This field is required.
Yes
No
29
Have there been any injuries to the face, mouth, or teeth?* This field is required.
YESNO
30
Has the child ever sucked a thumb or finger?* This field is required.
YESNO
31
Does the child have frequent canker or cold sores?* This field is required.
YESNO
32
Does the child have any speech problems? * This field is required.
YESNO
33
Are you a mouth breather while asleep?* This field is required.
YESNO
34
Are you a mouth breather while awake?* This field is required.
YESNO
35
Have you been informed of any missing or extra permanent teeth?* This field is required.
YESNO
36
Has the child ever had a previous orthodontic examination?* This field is required.
YESNO
37
Has anyone else in the family had orthodontic treatment?* This field is required.
YESNO
38
Is the child especially apprehensive toward dental visits?* This field is required.
YESNO
39
Does the child want orthodontic treatment?* This field is required.
40
List any musical instruments played* This field is required.
Huge
Large
Normal
Small
Ok
Ok
41
List any sports or hobbies* This field is required.
Huge
Large
Normal
Small
Ok
Ok
42
Reason for orthodontic consultation?* This field is required.
43
Adult Signature* This field is required.
Clear
Should be Empty: