Welcome to Align Orthodontics.

We know what a significant difference in health and self-esteem a beautiful smile can make. To make your first visit focused on you and informative, we would like to know about you. Together we will provide you with the healthy smile you deserve.


Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
Province:
Postal Code:
Primary Phone:
Alternate Phone:
Email:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
Are there any other parent or guardian involved in medical decision making? If so, who are they?
What are the names of any family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice (Family, Friends, Dentist)?

Emergency Information

Emergency Contact:
Phone:
Relationship to Patient:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
* Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?
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/therapy?
Clench or grind teeth?
Is there any incomplete dental care?
Have you had any facial or dental injuries?
Have you noticed any change in your bite or dental alignment recently?
Have you had any previous orthodontic treatment?
Do you want orthodontic treatment?
If there was something you could change about your smile, what would it be?
If any of the above dental questions were answered 'Yes', please explain:
Please check if there is a history of:
Muscular soreness around head and neck
Frequent headaches
Jaw joint soreness, clicking, popping
Ringing in ears
Speech problems (if so which sounds?)

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
Province:
Zip:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex?
Penicillin or other antibiotics?
Sulfa drugs?
Aspirin, Ibuprofen, or Tylenol?
Local anesthetics?
Codeine or other narcotics?
Other?
Please list any other allergies, drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Anemia, Blood Disorders
Kidney Disease
Herpes (Fever blisters)
Heart Surgery
Rheumatic Fever
Tuberculosis
Nervous/Anxious
Tonsillitis
Heart Valve Defect
Hives Rash
Bronchitis
Cancer
Fainting
Endocrine Disorders
Hepatitis
Asthma
Bone Disorders
Arthritis
Prolonged Bleeding
Diabetes
Epilepsy
Growth Disorders
None
Is there any other condition or problem that you think we should know about?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
Grade:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either biological parent ever had orthodontic treatment?

Financial Party Information

Primary Financially Responsible Party Person
First Name:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate of Responsible Party:
Address:
City:
Province:
Postal Code:
Email:
Primary Phone:
Alternate Phone:
Work Phone:
Is there a secondary financial party?
Secondary Financially Responsible Person
First Name:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate of Responsible Person:
Address:
City:
Province:
Postal Code:
Email:
Primary Phone:
Alternate Phone:
Work Phone:

Dental Insurance Information

Primary Insurance
Policy Holder/Subscriber Name:
Insurance Company Name:
Birthdate of Policy Holder:
Relationship to Patient:
Subscriber ID:
Group Number:
Do you have dual dental coverage?
(If yes, complete information below)
Secondary Insurance
Policy Holder/Subscriber Name:
Insurance Company Name:
Birthdate of Policy Holder:
Relationship to Patient:
Subscriber ID:
Group Number:

Kids Club for Children

Your little one may not be ready for treatment, but we'll make them feel welcome and have some fun! Would you like your younger children entered into our Kids Club database for orthodontic evaluation when age appropriate?
First Name:
Last Name:
Birthdate:
Gender:
First Name:
Last Name:
Birthdate:
Gender:

By signing below, I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

Patient/Parent/Guardian Signature: