Patient Information
First Name:
Last Name:
Gender:
Male
Female
Other
Address:
City:
Postal Code:
Province:
Main Phone:
Cell Phone:
Cell Phone Provider:
Email:
Birthdate:
Patient's Age:
Who may we thank for referring you to our office?
Financial/Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
City:
Province:
Postal Code:
Main Phone:
Cell Phone:
Cell Phone Provider:
Email:
Spouse First Name:
Last Name:
Cell Phone:
Cell Phone Provider:
Other First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
City:
Province:
Postal Code:
Main Phone:
Cell Phone:
Email:
Insurance Information
If you have an insurance plan which covers orthodontic treatment please complete the applicable information.
Policy Holder 1 Name:
Insurance Company Name:
Group Number:
Subscriber ID:
Birthdate:
Policy Holder 2 Name:
Insurance Company Name:
Group Number:
Subscriber ID:
Birthdate:
Please read carefully.
A dental insurance policy is a contract between the insured and the insurance company. Our office is to charge the patient directly for all the professional services rendered. To assist those of you with insurance coverage, when a payment is made, a reciept will be issued, along with an insurance verification which may simply be attached to one of your dental insurance claims and submitted to your insurance company for reimbursement. A pre-determination form, to determine the extent of your orthodontic coverage, will be provided to you in order that you may submit the required information to your insurance carrier prior to orthodontic treatment. If you have any further questions regarding insurance, please do not hesitate to ask.
Medical History
Please check any of the following conditions that apply:
Diabetes
Bone Disorders
Epilepsy
Gland Problems
Pneumonia
AIDS/HIV+
Asthma
Abnormal Bleeding
Heart Trouble
Arthritis
Kidney Involvement
Liver Involvement
Rheumatic Fever
Anemia
Hepatitis
Fainting & Dizziness
Nervous Disorder
Growth Disorder
Thyroid Diseases
Tuberculosis
Cancer
Frequent Cold/Sore Throat
Sinus/Nasal Congestion
Please indicate any allergies:
Are you in good health?
No
Yes
Have you been seriously ill or hospitalized?
No
Yes
Are you under the care of a physician?
No
Yes
Do you have trouble healing?
No
Yes
Are you pregnant?
No
Yes
Physician Name:
List current medications:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Please check if there is a history of:
Clenching/grinding
Muscle Soreness in head/neck
Mouth Breathing
Jaw joint soreness
Headaches
Sleep disorder
Jaw joing clicking/popping
Ringing in ears
Speech Problems
What is the patient's main orthodontic concern?
Crowding
Spacing
Overbite
Small teeth
Open bite
Prominent teeth
Crooked teeth
Underbite
Small lower jaw
Jaw pain or discomfort
Missing teeth
Prominent lower jaw
Finger thumb sucking
Other
Please explain if you answered Other:
Has the patient had previous orthodontic care?
No
Yes
If so, when?
Has a family member had orthodontic care?
No
Yes
Patient Privacy Policy
Please read carefully.
We are committed to protectcing the privacy of our patient's and using such infomration in a respectful and professional manner. All personal information is stored and protected in accordance with the Privacy Standards and Criteria as legislated by the Alberta Dental Association.
We collect personal information, such as names, birth dates, contact numbers and addresses for home, work, cell phone, email, and insurance detail for the following purposes.
To open and update patient files
To prepare billing, insurance claims, processing credit card payments, issue receipts for orthodontic services.
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies.
To send text and email appointment reminders, and email communication.
To send email communication regarding our orthodontic practice.
Additionally, this information may be disclosed to the following third parties:
Referral to medical and/or dental practiioner's for multidisciplinary treatments, which coinincide with orthodontic treatment.
Communication to health benefit providers and insurance companies on a patient's behalf
Orthodontic software support (which may be USA based) for management of patient files.
I consent to the collection, use and disclosure of my personal information as required for my orthodontic office.
Patient / Parent / Guardian Signature:
By typing my name above I am electronically signing this form.