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):