Child Patient Personal Information
Enter the child’s personal details and contact information, and provide any sibling information if applicable.
First Name
*
Middle Initial
Last Name
*
Preferred Name
Birthdate
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
0
01
011
0111
01111
Year
Gender
*
Male
Female
Other
Primary Address
*
City
*
Province
*
Postal Code
*
Primary Home Phone
Primary Cell Phone
*
Primary Email
*
example@example.com
Please list names and ages of siblings
Parent/Guardian Information
Back
Next
Mother's Title
Please Select
Dr.
Mr.
Mrs.
Ms.
Miss
First Name
*
Last Name
*
Address
*
City
*
Province
*
Postal Code
*
Home Phone
Cell Phone
*
Work Phone
Email
*
example@example.com
Occupation
Marital Status
Please Select
Single
Married
Divorced
Widowed
Separated
Common-law
Person Responsible For Medical Obligations
Back
Next
Dental History
Family Dentist
Date of last dental check-up
Dental Clinic Name
Clinic Phone No
Have You Seen an Orthodontist Before
*
YES
NO
If Yes, When?
If yes, who and where?
Have you ever required antibiotics or other medications prior to dental treatment?
*
YES
NO
If yes, please explain
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Jaw joint problems?
*
NO
YES
Grinding and/or clenching of teeth?
*
NO
YES
Thumb/finger sucking?
*
NO
YES
Injury to face or teeth?
*
NO
YES
Tongue position or swallowing problems?
*
NO
YES
Tonsils or adenoids removed?
*
NO
YES
Speech/articulation problems?
*
NO
YES
Back
Next
Mouth breathing more than nose breathing?
*
NO
YES
Medical History
Family Physician
Date of last medical check-up
Are you currently under medical care?
*
NO
YES
If yes, please explain
Please list any allergies you have
Please list any medications being taken
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Nickel/Metal allergy?
*
NO
YES
Latex allergy?
*
NO
YES
Rheumatic fever?
*
NO
YES
Epilepsy or Seizures?
*
NO
YES
Hereditary problems?
*
NO
YES
Asthma?
*
NO
YES
Headaches?
*
NO
YES
Hepatitis?
*
NO
YES
Heart murmur?
*
NO
YES
Heart problems?
*
NO
YES
H.I.V. positive?
*
NO
YES
Diabetes?
*
NO
YES
Anemia?
*
NO
YES
Prolonged bleeding?
*
NO
YES
Back
Next
Snoring or Sleep Apnea?
*
NO
YES
Please list any other conditions or treatments pertaining to your health that we should be aware of
Dental Insurance Information
Policy Subscriber's Full Name
Employer/Company Name
Insurance Company
Group/Policy Number
Certificate or I.D. Number
Subscriber's Date of Birth
Relationship to Patient
Please Select
Father
Mother
Self
Guardian
Other
Policy Subscriber's Full Name
Employer/Company Name
Insurance Company
Group/Policy Number
Back
Next
Certificate or I.D. Number
Subscriber's Date of Birth
Relationship to Patient
Please Select
Father
Mother
Self
Guardian
Other
Whom may we thank for referring you to our practice?
Reason for today's visit
I consent to having Dr. Lorne Kamelchuk do a clinical orthodontic examination and photographic documentation.
*
I consent to having Dr. Lorne Kamelchuk do a clinical orthodontic examination and photographic documentation.
I consent to the discretionary and anonymous use of my child's clinical photos and x-rays for Dr. Lorne Kamelchuk's educational/teaching purposes.
*
I consent to the discretionary and anonymous use of my child's clinical photos and x-rays for Dr. Lorne Kamelchuk's educational/teaching purposes.
SUBMIT
Should be Empty: