Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
Province:
Postal Code:
Main Phone:
2nd/Cell Phone:
Email:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
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:
Check if address is the same as the patient's.
Address:
City:
Province:
Postal Code:
Main Phone:
2nd/Cell Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Secondary Responsible Party
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
Check if address is the same as the patient's.
Address:
City:
Province:
Postal Code:
Main Phone:
2nd/Cell Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Neck/shoulder pain?
No
Yes
Frequent sore throats?
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
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
No
Yes
Please provide details as needed:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
Province:
Postal Code:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
No
Yes
Tuberculosis/Lung Disease
No
Yes
Pneumonia
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
Tonsils/Adenoids Removed
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Growth Problems
No
Yes
Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Latex/Metal Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Handicaps/Disabilities
No
Yes
Asthma
No
Yes
Arthritis
No
Yes
Treated for Emotional Problems
No
Yes
Ever Been Hospitalized
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid in our selection of treatment alternatives.
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
By sharing your email with Caledonia Orthodontics you agree to receive emails and texts from us regarding appointments, insurance, tax receipts, and other practice information, and understand that you can opt out at any time. Your email and personal information will not be shared with 3rd parties at any time. This electronic communication may not be secure. You understand that your patient record may be stored electronically in the cloud on a secure server with back up servers located in the US and Canada and as such subject to any and all US and Canadian laws.
Caledonia Orthodontics supports Personal Information Protection and Electronic Documents Act (PIPEDA). We understand the importance of protecting your personal information and are committed to collecting, using and disclosing your personal information responsibly. As a result, Caledonia Orthodontics has implemented a Privacy Code, which may be reviewed at any time, and a Privacy Information Officer, Dr. Ashley Phuong.
I hereby give Caledonia Orthodontics permission to release information concerning my dental and/or orthodontic condition to my family physician, dentist or any other dental specialist as is deemed necessary. This includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.
I know that your office has a Privacy Code, and I can ask to see the Code at any time.
I agree that Caledonia Orthodontics can collect, use and disclose my personal information as set out above in the information about the office privacy policies.
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for clinical examination.
By typing my name I am applying my electronic signature.
Signature:
Date: