If the patient is not a minor, 18 or younger : Go to Adult Form

PATIENT 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:

PARENTS / RESPONSIBLE PARTY (IF NOT PARENT)

Responsible Party I

Name:

Relationship:

Contact Number:

Occupation:

Email:

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

Insurance company:

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

Subscriber ID/Certificate Number:

Group/Policy Number:

Coverage:


Responsible Party 2

Name:

Relationship:

Contact Number:

Occupation:

Email:

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

Insurance company:

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

Subscriber ID/Certificate Number:

Group/Policy Number:

Coverage:

Dental / Medical History

Is your child in good general health? YesNo

How long ago was your child’s last visit to a dentist?

Has your child had any serious chronic illnesses or operations? YesNo

If yes, please specity

Does your child require pre­-medication before dental work? YesNo

If yes, what condition is that for?

Is your child taking any medications? YesNo

Please list:

Does your child have a history of (please click all that apply):Heart problemsAllergiesDiabetesAsthmaFaintingArthritisHepatitisRheumatic feverThumb/finger suckingNail bitingSnoringMouth breathing

Does your child experience (please click all that apply):
Difficulty opening the mouth / ‘Popping’ or ‘clicking’ noises from the jaw jointsPain around the ears or cheek / Pain on opening wide, chewing or yawningLocked or dislocated jaw

Has your child ever had injury to (please click all that apply):
The jawteethmouthheadneck

Does his/her bite feel uncomfortable or unusual? YesNo

Has your child been treated for TMJ (Temporomandibular disorder)? YesNo

Is he/she under any stress? YesNo

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

If yes, please explain:

Has your child had any previous orthodontic treatment? YesNo

If yes, please explain:

Has your child consulted with another orthodontist? YesNo

If yes, please explain:

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