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
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
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 relation
Financial Details
Who will be financially responsible for this account?
*
(ex. 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
Financially responsible party occupation:
Financially responsible party employer:
Financially responsible party work phone:
-
Area Code
Phone Number
Do you have orthodontic insurance?
*
Yes
No
Not sure
We do not bill dental 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
Primary insurance provider:
*
Will provide later
Not applicable
Manulife Financial Group
Canada Life
CINUP
Claimsecure Inc.
Co-operators Life Insurance Company
First Nations Health Authority
Ministry of Child & Family Development
Greenshield Canada
Health Insurance BC
MyGroupHEALTH Claims
Pacific Blue Cross
Sunlife Assurance Company
The Co-operators
Equitable Life
Insurance company
Primary policy holder name:
*
Policy holder date of birth:
*
-
Month
-
Day
Year
Date
Group number:
*
ID number:
*
Coverage percentage:
Lifetime limit:
Do you have another insurance policy to add?:
Yes
No
Secondary insurance provider:
*
Will provide later
Not applicable
Manulife Financial Group
Canada Life
CINUP
Claimsecure Inc.
Co-operators Life Insurance Company
First Nations Health Authority
Ministry of Child & Family Development
Greenshield Canada
Health Insurance BC
MyGroupHEALTH Claims
Pacific Blue Cross
Sunlife Assurance Company
The Co-operators
Insurance Company
Secondary policy holder name:
*
Policy holder date of birth:
*
-
Month
-
Day
Year
Date
Group number:
*
ID number:
*
Coverage percentage:
Lifetime limit:
Dental History
Were you referred to our office by your family dentist?
*
Yes
No
Let us know who referred you!
*
Does the patient currently have a dentist?
*
Yes
No
If you currently do not have a dentist, we would be happy to recommend one as their services may be required for orthodontic treatment.
Dentist's name
*
If the patient does not have a dentist please type "N/A"
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
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
Physician's name:
Physician phone:
-
Area Code
Phone Number
Is patient in good health?
Yes
No
Is the patient pregnant?
*
Yes
No
Not sure
Not applicable
Due date:
-
Month
-
Day
Year
Date
Is patient presently under a physician's care?
Yes
No
Reason for patient being under physician care:
Does the patient have a history of any major illness, genetic disorder or developmental delay?
*
Yes
No
Please explain:
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?
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:
Does the patient smoke?
Yes
No
Does the patient have a history of any of the following problems?
Diabetes
Rheumatic fever
Bone/growth disorders
Thyroid disease
Epilepsy
Please explain further:
Are there any other medical diagnoses we should be aware of?
Yes
No
Please explain further:
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.
Signature of responsible party
*
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