New Patient Information
Adult Intake Form
Patient full name:
*
First Name
Last Name
Patient preferred name:
Patient date of birth:
*
-
Month
-
Day
Year
Patient gender:
*
Male
Female
Identifies as:
Male
Female
Non-Binary
Other
If different than gender
Patient preferred pronouns:
She, her, hers
He, him, his
They, them, theirs
Patient's Marital Status
*
Married
Single
Divorced
Widowed
Common-Law
Separated
Primary Address:
*
Street Address
Street Address Line 2
City
Province
Postal Code
Primary phone number:
*
-
Area Code
Phone Number
Primary phone number type:
*
Home
Cell
Work
Other
Secondary phone number:
*
-
Area Code
Phone Number
Secondary phone number type:
*
Home
Cell
Work
Other
Primary email address:
*
example@example.com
Have any immediate family members been treated at our office?
*
Yes
No
Please list current and previously treated immediate family members:
*
Please list names and relationship to patient
Financial Details
If insurance is applicable, PLEASE complete all of the insurance questions. This information is required to help us prepare treatment costs.
Who will be financially responsible for this account?
*
(self, parents, father, mother, other)
Financially responsible party name:
*
Financially responsible party street address (IF different than primary address)
Street Address
Street Address Line 2
City
Province
Postal Code
Financially responsible party primary phone:
*
-
Area Code
Phone Number
Phone number type
*
Home
Cell
Work
Other
Do you have insurance? (If yes, the next following questions are required)
*
Please Select
Yes
No
We do not bill insurance companies or other third parties on patient's behalf. Accordingly, we will expect that payment be received directly from patients as services are provided. We will be pleased to prepare reports and claims for you to submit to insurance companies for reimbursement upon receipt of payment for services rendered.
REQUIRED* please upload a photo/screenshot of your insurance card to confirm the policy and ID numbers.
Browse Files
PLEASE MAKE SURE YOU ARE PROVIDING A DENTAL CARD AND NOT A MEDICAL CARD
Cancel
of
Group number:
ID number:
REQUIRED* Primary insurance provider:
Not applicable
Alberta Blue Cross
Canada Life
CDCP - Canadian Dental Care Plan
Chambers/CINUP/Johnston Group
Claimsecure
Desjardins Insurance
Empire Life
Equitable Life
FNHA - First Nations Health Authority
Greenshield Canada
GroupHealth
GroupSource
Health Insurance BC
IA Financial Group
Manulife Financial
Medavie Blue Cross
Ministry of Child & Family Development (PWD)
MyGroupHEALTH
Pacific Blue Cross
Sunlife Assurance Company
The Co-operators
Insurance company
REQUIRED* Primary policy holder's name:
First & Last
REQUIRED* Policy holder's date of birth:
-
Month
-
Day
Year
Date
REQUIRED* Primary's relationship to patient:
Mother, Father, Step-parent, Self
REQUIRED* Primary employer:
Business/company name
REQUIRED* Primary employer's address:
Business/company address
REQUIRED* Primary employer's phone:
-
Area Code
Phone Number
REQUIRED* Please select your employment status:
Please Select
Full-Time Employee
Full-Time Student
Part-Time Employee
Part-Time Student
Retired
Do you have a secondary insurance to add?:
*
Please Select
Yes
No
*Only required if there is a SECONDARY insurance plan* Please upload a photo/screenshot of your insurance card to confirm the policy and ID numbers.
Browse Files
Cancel
of
Group number:
ID number:
REQUIRED* Secondary insurance provider:
Not applicable
Alberta Blue Cross
Canada Life
CDCP - Canadian Dental Care Plan
Chambers/CINUP/Johnston Group
Claimsecure
Desjardins Insurance
Empire Life
Equitable Life
FNHA - First Nations Health Authority
Greenshield Canada
Group Source
Health Insurance BC
IA Financial Group
Manulife Financial
Medavie Blue Cross
Ministry of Child & Family Development (PWD)
MyGroupHEALTH
Pacific Blue Cross
Sunlife Assurance Company
The Co-operators
Insurance Company
REQUIRED* Secondary policy holder's name:
First & Last
REQUIRED* Policy holder's date of birth:
-
Month
-
Day
Year
Date
REQUIRED* Secondary's relationship to patient:
Mother, Father, Step-parent, Self
REQUIRED* Secondary employer:
Business/company name
REQUIRED* Secondary employer's address:
Business/company address
REQUIRED* Secondary employer's phone:
-
Area Code
Phone Number
REQUIRED* Please select your employment status:
Please Select
Full-Time Employee
Full-Time Student
Part-Time Employee
Part-Time Student
Retired
Dental History
Does the patient currently have a dentist?
*
Yes
No
Dentist's first and last name, as there are multiple dental professionals with the same last name
*
If the patient does not have a dentist, please type "N/A"
Dental practice name
*
Last dentist visit
*
-
Month
-
Day
Year
If unsure of exact date, an approximate date is sufficient.
What was completed at the last dentist visit?
*
Check-up & Cleaning
Fillings
Restorations
Emergency
Extractions
Crowns
Root Canal
Bonding
Other
If you currently do not have a dentist, we would be happy to recommend one as their services may be required for orthodontic treatment.
Have there been any injuries to the face or mouth?
*
Yes
No
Please explain the injuries:
Has the patient ever had an oral habit? (Thumb, finger, soother?)
*
Yes
No
Not sure
What was the oral habit?
Thumb
Finger
Soother/Pacifier
Other
At what age did the habit stop?
Does the patient have a tongue thrust?
*
Yes
No
Not sure
Does the patient have any trouble with speech?
*
Yes
No
Not sure
Please explain the speech challenges:
Does the patient have a difficult time breathing through their nose?
*
Yes
No
Not sure
Rate the patient's oral hygiene:
*
Excellent
Good
Fair
Could Use Improvement
Is the patient flossing?
*
Regularly
Once in a while
Rarely
Medical History
Is patient presently under a physician's care?
*
Yes
No
Reason for patient being under physician's care:
Does the patient have a history of any major illness, genetic disorder or developmental delay?
*
Yes
No
Please explain:
Is the patient pregnant?
*
Yes
No
Not sure
Not applicable
Due date:
-
Month
-
Day
Year
Date
Does the patient snore?
*
Yes
No
Any problems with tonsils or adenoids?
*
Yes
No
Have tonsils or adenoids been removed?
*
Yes
No
At what age were the tonsils or adenoids removed?
Does the patient smoke?
*
Yes
No
Is the patient on any prescribed drugs or medications?
*
Yes
No
List any drugs or medications currently being taken:
*
Reason for medication:
*
Please list any allergies and/or drug sensitivities:
Are there any other medical diagnoses we should be aware of?
*
Yes
No
Please explain further:
Orthodontic Goals
What is your primary Orthodontic concern?
*
What treatment option(s) interest you?
*
Clear Aligners
Metal Braces
Retainers only
If Other, please explain:
Other
If Orthodontic treatment is recommended, how soon would you like to get started?
*
ASAP
Within the month
Within 6 months
If Other, please explain:
Other
How did you learn about our practice or whom may we thank for referring you?
*
Referred by Dentist
Family/Friend
Google
Instagram
Facebook
If Other, please list source:
Other
Consent
I understand that the information I have given is correct, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes. I authorize the orthodontic staff to perform necessary diagnostic and orthodontic procedures. During the initial orthodontic examination, video or photographs may be taken for clinical documentation and training purposes. By signing this form, you provide consent for this use. If you prefer not to have video taken during your examination, please inform your treatment coordinator directly.
Signature of responsible party
*
Submit
Should be Empty: