Patient Information Title * Mr. Mrs. Ms. Miss. Dr. Sex * Male Female Other Patient First Name * Patient Middle Name Patient Last Name * Patient Preferred Name Date of Birth * Age * Best number for appt confirmation by text * Home Phone Cell Phone * Work Phone Email Address ( Responsible Party ) * Address * City * State * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Who may we thank for referring you to our office? * Name of School Siblings? Yes No Responsible Party Information Parent #1 Full Name * Title * Mr. Mrs. Ms. Miss. Dr. Relationship to patient * Martial Status * Single Married Divorced Widowed Email Address * Cell Phone * Work Phone * Address City State Province * Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Responsible Party Information Parent #2 Full Name * Title * Mr. Mrs. Ms. Miss. Dr. Relationship to patient * Martial Status * Single Married Divorced Widowed Email Address Cell Phone Work Phone Address City State Province * Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code * Insurance Information Do you have dental insurance? * Yes No Member's Full Name on the policy Birthdate Name of Insurance Company Policy / Group / ID # Certificate # Name of Group or Policy holder or Employer Medical and Dental History of the Patient Pregnant? * Yes No Smoker * Yes No Patient has history of medical conditions? * Yes No Currently under any medical treatments? * Yes No Check all history medical condition that apply * Arthritis Diabetes Epilepsy Anemia HIV Asthma Bleeding Disorder High Blood Pressure Hepatitis A Hepatitis A Hepatitis C OtherOther Current Medical Treatment(s) * Currently under any medications? * Yes No Do you need to be premedicated? * Yes No Do you carry an EpiPen? * Yes No Allergies * Yes No Medications * List any allergies * Is there a heart condition? * Yes No Is there a tendency to faint or become dizzy? * Yes No Is there any pain, clicking, and/or popping noise in the jaw? * Yes No Are you aware of either clenching or grinding teeth? * Yes No Please describe heart condition * Please describe tendency * Is there frequent snoring and/or sleep apnea? * Yes No Any habits? * Yes No Are there any speech problems? * Yes No have there been any injuries to the teeth? * Yes No Habits * Nail Biting Finger or thumb sucking Lip or cheek biting Tongue Thrusting Mouth Breathing Describe speech problem(s) * Describe injuries * Patient's Current Dentist's Name * Dentist's Phone Patient's Current Family Doctor's Name Doctor's Phone I hereby consents to have my orthodontic records and information discussed with my dental, medical and insurance parties. * Agree Patient Signature (Parent Signature if Minor) * Clear reCAPTCHA If you are human, leave this field blank. Δ
