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
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
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
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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
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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: