PATIENT INFORMATION:

    First Name:*

    Last Name:*

    Gender:*
    MaleFemale

    Date of Birth:*

    Address:*

    City:*

    Postal code:*

    Home Phone:*

    Cell Phone:*

    Email:*

    Best Time To Call:

    School:

    Family Dentist:

    How did you hear about our office?
    DentistNewspaperInternetFriendsOther

    Dentist/Other:

    PARENTS / RESPONSIBLE PARTY (IF NOT PARENT)

    Parent I

    Name:

    Relationship with patient:

    Occupation:

    Contact #:

    Email:

    Dental Insurance

    Do you have DENTAL INSURANCE that covers orthodontic treatment?
    yesno

    Insurance company:

    Employer:

    Date of Birth:

    Subscriber ID/Certificate #:

    Group/Policy #:

    Coverage:

    Parent II

    Name:

    Relationship with patient:

    Occupation:

    Contact #:

    Email:

    Dental Insurance

    Do you have DENTAL INSURANCE that covers orthodontic treatment?
    yesno

    Insurance company:

    Employer:

    Date of Birth:

    Subscriber ID/Certificate #:

    Group/Policy #:

    Coverage:

    Dental / Medical History

    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: