Electronic Health History
  PATIENT INFORMATION    
*Last Name:  
*First Name:  
Middle Initial:
*Gender:  
*Birthdate: (mm/dd/yyyy)    
Age:
School: (If applicable)
*Address:  
*City/Town  
*Province:  
*Postal Code:  
*Main Phone:  
Cell Phone:
Cell Phone Provider:
ie: rogers, telus, shaw, bell, etc.
Whom may we thank for referring you to our practice?
  FINANCIAL/RESPONSIBLE PARTY INFORMATION   
*Last Name:  
*First Name:  
Address:  
*City:  
*Province:  
*Postal Code:  
Last Name:
First Name:
Address:
City:
Province:
Zip:
*Main Phone:  
Cell Phone:
Cell Phone Provider:
ie: rogers, telus, shaw, bell, etc.
Email:
Relationship to Patient:
Main Phone:
Cell Phone:
Cell Phone Provider:
ie: rogers, telus, shaw, bell, etc.
Email:
Relationship to Patient:
  INSURANCE INFORMATION (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 professional services rendered. To assist those of you with insurance coverage, when a payment is made, a receipt will be issued, along with a dental claim form for you to submit to your insurance company for reimbursement. If you have any further questions regarding insurance, please do not hesitate to ask.
Do you have an insurance plan that covers orthodontic treatment?
 
Relationship to Patient Name of Insurance Co.
 
 
Group/Policy # Certificate/ID #
   MEDICAL HISTORY     
Please select YES to any of the following conditions that apply to the patient. Cannot be blank.
  Diabetes
  Pneumonia
  Heart Trouble
  Rheumatic Fever
  Nervous Disorders
  Abnormal Healing
  Bone Disorders
  AIDS/HIV+
  Arthritis
  Anemia
  Growth Disorder
  Frequent Headaches
  Cancer
  Seizures/Epilepsy
  Asthma
  Kidney Involvement
  Hepatitis
  Thyroid Disease
  Nasal/Sinus Congestion
  Gland Problems
  Liver Involvement
  Fainting & Dizziness
  Tuberculosis
 Is patient in good health?
 Has patiently been seriously ill or hospitalized?
 Is patient under the care of a physician?
Physician's Name:  
Phone #:  
Please indicate any allergies:
Please describe medical conditions not otherwise specified:
Please indicate if your child has any special needs or concerns:
  DENTAL HISTORY     
Dentist's Name:
Frequency of Dental Checkups:
Last Dental Visit: (mm/dd/yyyy)  
Do you have any unfinished dental work?

Please select YES if there is a history of the following. Cannot be blank.
  Clenching/Grinding
  Muscle soreness in head/neck
  Ringing in ears
  Jaw joint soreness
  Headaches
  Jaw joint clicking/popping
  Speech Problems
If so, which sounds:
  Mouth breathing: Awake
  Mouth breathing: Asleep
Main Orthodontic Concern:
 
 
 
 
 
 
 
Other:
Has the patient had previous orthodontic care?  
Please Specify:
  PATIENT PRIVACY POLICY (PLEASE READ CAREFULLY)    
We are committed to protecting the privacy of our patient's personal information and to use all personal information in a responsible and professional manner. We collect information to open and update patient files, to process payments, to prepare insurance claim forms and to communicate with patients and their families. We collect medical/dental information for the purpose of diagnosis and treatment planning. As required, we share records and pertinent information with other medical and dental professionals. Complete details of our Patient Privacy Policy are available upon request.
I       consent to the collection, use and disclosure of my personal information as required for my orthodontic treatment.