Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
Province:
Postal Code:
Mobile Phone:
Email:
Financial Party Information
Check if address and contact information are the same as the patient.
First Name:
Middle Initial:
Last Name:
Birthdate (Needed for insurance purposes):
Mobile Phone:
Email:
Address:
City:
Province:
Postal Code:
Is there another parent that will be financially responsible?
No
Yes
Check if address is the same as the patient.
First Name:
Middle Initial:
Last Name:
Birthdate (Needed for insurance purposes):
Mobile Phone:
Email:
Address:
City:
Province:
Postal Code:
Dental History
Dentist Name:
Checkup Frequency:
Every 3 months
Every 6 months
Every 9 months
Once a year
It has been more than 1 year
I do not go to the dentist
LastDentistVisit
Less than 6 months
More than 6 months
More than 1 year
I do not go to the dentist
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems or therapy?
No
Yes
Clench or grind teeth?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently chew gum?
No
Yes
Additional dental information:
Medical History
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies or sensitivities that the patient may have and what happens:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Hemophilia?
No
Yes
HIV or AIDS?
No
Yes
Hepatitis?
No
Yes
Radiation treatment?
No
Yes
Growth problems?
No
Yes
Latex or Metal Allergy?
No
Yes
Bone disorders or loss?
No
Yes
Diabetes?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Handicaps or disabilities?
No
Yes
Additional medical information:
Orthodontic Treatment
Please let us know what you would like to see changed about your/your child's smile?
Generally align teeth
Fix overbite
Fix my bite
Just need a minor touch up
Make space
Early preventative treatment (11 years and younger)
Other
Has the patient ever been to an orthodontist before?
No
Yes
If yes, where and when
I am interested in:
Traditional braces - wires with colours
Clear aligners (Invisalign)
I'm open to learning about both options
Early preventative treatment (children under the age of 11)
We do offer a complimentary direct billing service and 0% interest payment plans.
Do you have dental insurance to go towards treatment costs?
No
Yes
When would you like to get your/your child's smile transformation started?
Right away if recommended by doctor
I only want treatment if necessary
Wait for insurance to be active first
I want to learn about 0% financing option
Other
Do you have any family or friends at our office we can thank for referring you?