Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
Province:
Postal Code:
Main Phone:
2nd Phone:
Email:
Please list the names of any friends or family treated at Hurd Tomson Orthodontics:
List any sports, hobbies, or musical instruments played:
How did you hear about our office?
Dentist
Family/Friend
Google
Facebook
Instagram
Staff Member
Sign/Drive By
Sponsorship
Staff
Word of Mouth
Parent/Guardian #1 Name:
Parent/Guardian #1 Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Parent/Guardian #1 Email:
Parent/Guardian #1 Cell Phone:
Parent/Guardian #2 Name:
Parent/Guardian #2 Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Parent/Guardian #2 Email:
Parent/Guardian #2 Cell Phone:
If Parent/Guardian has a different address than the child, please specify:
Sibling names and ages:
Patient's School
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
Address:
City:
Province:
Postal Code:
Main Phone:
2nd Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Policy Holder Name:
Policy Holder Date of Birth:
Policy or Group Number:
ID or Certificate Number:
If there is dual coverage, please provide the secondary insurance information below:
Policy Holder Name:
Policy Holder Date of Birth:
Policy or Group Number:
ID or Certificate Number:
Dental and Medical History
Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario and the law. Only necessary information is collected and we only share information with your consent.
What is your reason for an orthodontic consultation?
Are there any other family members with a similar jaw problem?
Name of Patient's Dentist:
Date of Last Visit:
Name of Patient's Family Physician:
Name(s) of any Medical Specialists being seen currently:
Please select Yes for any of the following which apply to the patient and add any relevant comments.
Are you taking any medication?
Yes
No
Comment:
Are you allergic to or had any adverse reaction to any medication?
Yes
No
Comment:
Is there any history of a thumb or finger sucking habit?
Yes
No
If so, when did the habit stop?
Have tonsils or adenoids been removed?
Yes
No
If so, at what age?
Do you have a history of any major illness?
Yes
No
Comment:
Have you had any major operations?
Yes
No
Comment:
Have you ever been involved in a serious accident?
Yes
No
Comment:
Please check any of the following that you have had or currently have:
Abnormal bleeding/Hemophilia
Yes
No
Allergy to Latex
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Bone Disorders
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty breathing through the nose
Yes
No
Dizziness
Yes
No
Epilepsy
Yes
No
Gastrointestinal Disorders
Yes
No
Heart Problems
Yes
No
Heart Murmur
Yes
No
Hepatitis/Liver Problems
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
HIV/Aids
Yes
No
Kidney Problems
Yes
No
Pain in the jaw Joints (TMJ disorder)
Yes
No
Pneumonia
Yes
No
Nervous Disorders
Yes
No
Prolonged Bleeding
Yes
No
Radiation/Chemotherapy
Yes
No
Rheumatic Fever
Yes
No
Tuberculosis
Yes
No
Tumor or Cancer
Yes
No
Unusual Number of Headaches
Yes
No
Are there any medical conditions we have not discussed that you feel we should be aware of?
Allergy to quinilone and aminoglycoside antibiotics
Yes
No
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other