Date of Birth:*
Best Time To Call:
How did you hear about our office?
Relationship with patient:
Do you have DENTAL INSURANCE that covers orthodontic treatment?
Date of Birth:
Subscriber ID/Certificate #:
Is your child in good general health? YesNo
Has your child had any serious chronic illnesses or operations? YesNo
How long ago was your child’s last visit to a dentist?
Does your child require pre-medication before dental work? If yes, what condition is this for? YesNo
Is your child taking any medications? Please list:
Does your child have a history of:Heart problemsAllergiesDiabetesAsthmaFaintingArthritisHepatitisRheumatic feverThumb/finger suckingNail bitingSnoringMouth breathing
Does your child experience: 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: 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?
Have you consulted with another orthodontist? YesNo
Has he/she had any previous orthodontic treatment? YesNo
If yes, please explain:
Last radiograph taken (Panoramic Xray):
If you answered to yes for any of the above, please explain:
120 – 1960 Como Lake Ave. Coquitlam, BC V3J 3R3
Mon: 10am – 6pm Tue: 10am – 5pm (Off-site reception) Thu: 9am – 5pm Fri: 9am – 5pm Sat: 9am – 4pm Once a month PHONE: 604 – 671 – 2255
E-MAIL: [email protected]
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