As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. The information you provide below is crucial in allowing us to provide appropriate care for you. Uptown Orthodontics does not use this information to discriminate.

Patient Information

First Name:
Last Name:
Gender:
Preferred Name:
Birthdate:
Age:
Health Number: (required if covered under the Supplementary Health or Family Health Benefits Program)
Status Card Number: (if applicable)
School: (if patient is a student)
To help our team discuss potential effects of orthodontic treatment on regular activities, please list any sports or hobbies in which the patient is involved, or any musical instruments played.
To help our team assess growth and development, for patients under the age of 20, please list all siblings by name including their age, gender, and approximate height.

SIBLING 1

Name:
Age:
Gender:
Approximate Height:

SIBLING 2

Name:
Age:
Gender:
Approximate Height:

SIBLING 3

Name:
Age:
Gender:
Approximate Height:

SIBLING 4

Name:
Age:
Gender:
Approximate Height:
Please provide the names of any friends or family currently or previously treated at Uptown Orthodontics.
How did you hear about Uptown Orthodontics?
If 'other' please describe:

Primary Person Responsible for Account at Uptown Orthodontics

Relationship to Patient:
if other, describe relationship:
First Name:
Last Name:
Email:
Home Phone:
Mobile Phone:
Work Phone:
Home Address:
City/Town:
Province:
Postal Code:
Employer:
Occupation:
* Desired correspondence for appointment reminders:

If Applicable, Secondary Person Responsible for Patient

Relationship to Patient:
if other, describe relationship:
First Name:
Last Name:
Email:
Home Phone:
Mobile Phone:
Work Phone:
Home Address:
City/Town:
Province:
Postal Code:
Employer:
Occupation:
Desired correspondence for appointment reminders:

Private Orthodontic Insurance (required if applicable)

This information, if provided, allows us to prepare necessary submission forms that we will then provide to you for submission. Please note that all insurance cards listed below must still be brought to your initial appointment to allow for verification of the numbers provided to ensure any submissions made can proceed without problems/delays.

POLICY 1

Policy Holder's Name:
PH's Birthdate:
Insurance Provider (e.g. Blue Cross):
Policy/Group/Plan Number:
PH's Member ID:

POLICY 2

Policy Holder's Name:
PH's Birthdate:
Insurance Provider:
Policy/Group/Plan Number:
PH's Member ID:

POLICY 3

Policy Holder's Name:
PH's Birthdate:
Insurance Provider:
Policy/Group/Plan Number:
PH's Member ID:

POLICY 4

Policy Holder's Name:
PH's Birthdate:
Insurance Provider:
Policy/Group/Plan Number:
PH's Member ID:

Dental Information

Dentist:
Office/Location:
Last Dental Visit (estimate, if unknown):
IMPORTANT: What is the primary reason for seeking an orthodontic consultation? (Describe the patient's main concern regarding his/her teeth, smile, or bite.) Please be specific.
Does the patient want orthodontic treatment?
If the patient is a candidate for orthodontic tooth movement, I/we would be interested in the following modality of treatment:
If 'other' in the previous question, please describe any preferences:
In any treatment provided, I/we are most concerned about: (check as many as apply)
If 'other' in the previous question, please describe your major concern:
Has the patient had an orthodontic consultation or any orthodontic treatment in the past?
If 'yes' to the previous question, when and where were you seen previously (or who were you seen by), and most importantly, what, if anything, was done?

*Check any of the following habits (daily or almost daily occurrences) that apply to the patient currently or have applied within the last 5 years.
If 'other' in the previous question, please describe:
*Check any of the following functional problems that apply to the patient currently.
If 'other' in the previous question, please describe:
Does the patient experience daily pain or locking with the jaw joint (TMJ)?
If 'yes' to the previous question, please describe:
How often does the patient brush his/her teeth?
How often does the patient floss his/her teeth? (please check one)
*Check any of the following past dental occurrences that may apply to the patient.
If anything except 'none' was selected in the previous question, please describe, including relevant timelines.

*Check any of the following future dental plans that may apply to the patient.
If anything except 'none' was selected in the previous question, please describe, including relevant timelines.

Medical Information

Doctor:
Office/Location:
Last Visit (estimate, if unknown):
Is the patient currently under the care of a medical professional for an ongoing, specific condition?
If 'yes', to the previous question, please describe.
Is the patient currently taking any prescription medications, over-the-counter medications, vitamins, natural or herbal preparations, or diet supplements?
If 'yes' to the previous question, please describe.
*Check any of the following categories that have been known to lead to significant allergies or severe adverse reactions in the patient.
If anything except 'none' was selected in the previous question, please describe.
Has a physician or dentist ever recommended the patient take antibiotics or other medication prior to any dental treatment because of a medical condition?
If 'yes' to the previous question, who made the suggestion and what did they suggest?
Has the patient had his/her tonsils or adenoids removed?
FOR FEMALE PATIENTS ONLY: Is the patient pregnant?
If 'yes' to the previous question, what is the due date?
*Check any of the following conditions or occurrences that are currently (or were in the recent past) applicable to the patient.
If anything except 'none' was selected in the previous question, please describe below any relevant timelines, any treatment received, and current status.
Describe any other medical condition, disease, or problem not listed above that the patient has had, or is currently being treated for.

NOTE: Both the doctor and the patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that the orthodontist and his/her staff will rely on this information for providing treatment. I will not hold the orthodontist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Consent for Records: I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examination, treatment, or retention, for purposes of professional consultation, third-party appliance manufacturing, research, and education.

Name of Person Who Completed This Form:
Relationship to Patient:
Digital Signature (Please Type Name):
Date:

Our office software may disclose your information to third party organizations to perform activities such as processing and storage of your information. Some of these organizations may use facilities and resources located outside of Canada and accordingly your personal information may be collected, used, disclosed, stored, processed, and destroyed outside of Canada for the purposes described. As a result, your personal information may be subjected to the laws of foreign jurisdictions (including those of the United States of America) and may be available to foreign governments or their agencies under a lawful order or through other judicial processes.