Patient information form Once you have booked an inital consultation please fill out this form prior to your appointment, or if your perfer download the form and print it off. Please contact our office if you require assistance. Patient Information Patient Name Parent/Guardian Name Additional Parent/Guardian Name Age Date of Birth JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Sex---femalemale Address City Province Postal Code Phone (Home) Phone (Cell) Phone (Work) Dentist Physician Who may we thank for referring you? Account Information Personal responsible for account Title---Mrs.Mr.Ms.Dr. Name Email Address Address City Province Postal Code Dental Insurance We do not bill dental insurance companies directly. Payment from the responsible party is required at the time the service is provided. We will aid you with preparing your insurance claims so that you may receive reimbursement directly from your insurance company. Enter insurance policy informationNoOne policyTwo policies Insurance Policy #1 Name of Policy Holder Relationship to Patient Address City Province Postal Code Date of Birth Employer Insurance Company Group ID/Certificate Patient's Dependent # % Ortho Coverage Coverage Limit Insurance Policy #2 Name of Policy Holder Relationship to Patient Address City Province Postal Code Date of Birth Employer Insurance Company Group ID/Certificate Patient's Dependent # % Ortho Coverage Coverage Limit Medical History Is the patient in good health?yesno Is the patient under a physician's care?yesno If yes, briefly describe Please list any drugs and/or medications being taken Give reasons Does the patient have any allergies or drug sensitivities Does the patient have a history of any of the following?DiabetesHeart MurmurEpilepsyHepatitisRheumatic FeverBone DisorderThyroid DiseaseProlonged Bleeding Does the patient require antibiotic premedication before dental treatment?yesno Have the tonsils/adenoids been removed?yesno If so, what age? Dental History Has there ever been any injury to the face, mouth, or teeth?yesno If yes, please briefly describe Has the patient ever sucked a thumb or finger?yesno Is the patient a mouth breather?awakesleepingbothno Has the patient ever been informed of any missing or extra teeth?yesno Has the patient ever had a previous orthodontic exam?yesno Do any relatives have a similar tooth or jaw condition as the patient?yesno If yes, please briefly describe Has any family member been previously treated in this office? When did the patient last have dental care? Briefly state what you would like to achieve with orthodontic treatment Please list any sports, hobbies, and/or interests ANY INFORMATION PROVIDED WILL BE HELD IN STRICTEST CONFIDENCE. PLEASE INFORM THE OFFICE IF ANY OF THE ABOVE INFORMATION CHANGES DURING THE COURSE OF TREATMENT.