Date
-
Month
-
Day
Year
Date
Your Childs information
Please complete information below
First name
*
Last Name
*
Childs middle name
Gender at birth
*
Please Select
Female
Male
Gender preference
Please Select
Female
Male
Transgender
Non-binary/non conforming
Prefer not to respond
Date of birth
-
Month
-
Day
Year
Date
Patients age in
years
and
months
STREET
*
CITY
*
POSTAL CODE
*
Phone number
*
Email Address
*
example@example.com
Name of school they attend
Grade in school
Parent/Guardian
Please complete all that applies
Parent/Guardian 1
*
First Name
Last Name
Phone number
*
Email
*
example@example.com
Parent/Guardian 2
First Name
Last Name
Phone Number
Email
example@example.com
Please indicate the following:
Married
Separated
Divorced
Common-Law
Widowed
Who will be responsible for the account?
*
Please Select
Parent/Guardian 1
Parent/Guardian 2
Both
Other
If you answered Other please complete
Dentist information
Dentist Name
*
Dentist phone number
Who can we thank for the referral?
Insurance coverage information
Do you have orthodontic coverage?
*
Yes
No
Other
Other - please elaborate
Plan name 1
Coverage
Maximum
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Plan Name 2
Coverage
Maximum
Policy Holder Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Name
*
Emergency Contact Telephone
*
Relationship
If the patient has seen an Orthodontist before, please complete the following:
Name of Orthodontist
Phone Number
Address
Province/State
Date of last visit
/
Month
/
Day
Year
Date
Date braces removed or to be removed
/
Month
/
Day
Year
Date
Remarks
PATIENT INFORMATION:
Medical History
Is the patient in good health
*
Yes
No
If No please explain
Any major or unusual illnesses?
*
Yes
No
If yes please explain:
Are they currently under the care of a physician?
*
Yes
No
Reason
Are they currently taking any medications/supplements?
*
Yes
No
List & Reason
Does the patient have any allergies?
*
Yes
No
Please list
Does the patient have any drug sensitivities?
*
Yes
No
Please list
Name of Family Physician
*
Phone number of Family Physician
*
Has the patient had or does the patient have any of the following?
Anaemia
*
Yes
No
Blood Disease
*
Yes
No
Prolonged bleeding
*
Yes
No
Hepatitis
*
Yes
No
HIV/AIDS
*
Yes
No
Jaundice
*
Yes
No
Rheumatic Fever
*
Yes
No
Heart Disease
*
Yes
No
Tuberculosis
*
Yes
No
Diabetes
*
Yes
No
Endocrine Problems
*
Yes
No
Bone Disorders - including Osteoporosis
*
Yes
No
Epilepsy
*
Yes
No
Herpes - including cold sores
*
Yes
No
Learning disorders
*
Yes
No
ADHD/ADD
*
Yes
No
Frequent colds
*
Yes
No
Tonsillitis
*
Yes
No
Tonsils removed
Yes
No
Patients age when tonsils removed
Adenitis
*
Yes
No
Adenoids removed
Yes
No
Patients age when adenoids removed
Asthma
*
Yes
No
Snoring/Sleep Apnea
*
Yes
No
Mouth Breathing
*
Yes
No
Mouth breathing
While Awake
While Asleep
Has the patient had any severe head or face injuries?
*
Yes
No
If yes please describe
Has the patient had any previous dental trauma?
*
Yes
No
If yes, which teeth?
Has the patient had a history of thumbsucking or fingersucking?
*
Yes
No
Stopped at what age?
Does the patient play any musical instruments?
*
Yes
No
Which instruments?
Has the patient had orthodontic treatment recommended before?
*
Yes
No
If orthodontic treatment has been recommended, what has been recommended?
Has the patient had previous orthodontic treatment?
*
Yes
No
What treatment has the patient had?
Approximate Date of last dental visit
/
Month
/
Day
Year
Date
Does the patient have or has had any of the following?
Clenching teeth
*
Yes
No
Headaches (More than normal)
*
Yes
No
Grinding teeth
*
Yes
No
Muscular soreness around head and neck
*
Yes
No
Joint Soreness
*
Yes
No
Jaw joint clicking
*
Yes
No
Jaw joint popping
*
Yes
No
Ringing in ears
*
Yes
No
Other concerns
*
Yes
No
Complete if you answered yes to other concerns
What is your main orthodontic concern?
Is there any other information that may be helpful?
GROWTH INFORMATION FOR PATIENT UNDER 16 YEARS OF AGE
Father's Height
Mother's Height
Patient's Height
Is the patient adopted
Yes
Patient resembles
Neither parent
Mother
Father
For girls: Has she started menstruation?
Yes
No
If menstruation has begun, when?
For Boys: Has his voice changed
Yes
No
If voice has changed, when did it happen?
Siblings:
Have any siblings had orthodontic treatment?
Yes
No
Name and age of all siblings
Submit
Should be Empty: