If the patient is a minor, 18 or younger : Go to Child Form

Patient’s Information:

First Name:*

Last Name:*

Gender:*
MaleFemale

Date of Birth:*

Address:*

City:*

Province:*

Postal code:*

Email:*

Phone Number 1:*

Phone Number 2:

How did you hear about our office?*
DentistNewspaperFriendsInternetOther

If you checked dentist, please specify:

If you checked other, please specify:

Dental Insurance

Do you have DENTAL INSURANCE that covers orthodontic treatment?
yesno

Our office will try to get your coverage information in advance for you with your permission:
yesno

Name of the plan holder:

Relationship to the plan holder:
SelfSpouseDependant

Insurance company:

Plan holder's Date of Birth (YYYY-MM-DD):

Subscriber ID/Certificate Number:

Group/Policy Number:

Coverage:

Dental / Medical History

Are you in good general health? YesNo

When was your last visit to a family doctor?

How long ago was your last visit to a dentist?

Have you had any serious chronic illnesses or operations? YesNo

If yes, please specify

Do you require pre-medication before dental work? YesNo

If yes, what condition is that for?

Are you taking any medications? YesNo

If yes, please list:

Do you have a history of (please click all that apply):Heart problemsAllergiesDiabetesAsthmaFaintingArthritisHepatitisRheumatic feverSnoringMouth breathing

Do you have a history of (please click all that apply):Difficulty opening the mouth'Popping' or 'Clicking' noises from the jaw jointsPain around the ears or cheekPain on opening wide, chewing or yawningLocked or dislocated jaw

Have you ever had injury to (please click all that apply):The JawTeethMouthHeadNeck

Does your bite feel uncomfortable or unusual? YesNo

Have you been treated for TMJ (Temporomandibular disorder)? YesNo

Are you under any stress? YesNo

Is there any other health information that we should know about? YesNo

If yes, please explain:

Have you had any previous orthodontic treatment? YesNo

If yes, please explain:

Have you consulted with another orthodontist? YesNo

If yes, please explain:

When was the last radiographs taken? (Panoramic X-ray, if there is any):