Confidential Patient Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*Province:  
*Postal Code:  
*Main Phone:  
*Phone Type:  
2nd/Cell Phone:
Email:
Occupation:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?   
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?
  Confidential Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
Marital Status:
*Main Phone:  
*Phone Type:  
2nd/Cell Phone:
Email:
*Birthdate:    
Relationship to Patient:
*Address:  
*City:  
*Province:  
*Postal Code:  
Work Phone #:
   
   
   
   
   
   
   
Spouse or Other Parent's First Name
Middle Initial:
Last Name:
Birthdate:  
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Do you receive funds through: (Check all that apply)
 
Primary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
Province:
Postal Code:
Insurance Co. Phone No.:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
Province:
Postal Code:
Insurance Co. Phone No.:
Relationship to Patient:
  Dental History     
Dentist Name:
Check-up Frequency:   
Last Dental Visit:  
Reason for visit:
Has the patient had an orthodontic consult or treatment?
If so, when?

Are you happy with your smile?    If no, why?  
  Does the Patient need to premedicate prior to dental visit?    
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Speech problems/therapy?
  Clench or Grind Teeth?
  Injury to face, jaw, teeth or mouth?
  Chipped or injured permanent teeth?
  Brush teeth daily?
  Floss teeth daily?
  Mouth breathing?
  Any missing or extra permanent teeth?
  Thumb or finger habit as a child?
If any of the above dental questions were answered 'Yes', please explain:
  Have you had a TMJ screening?   Do you experience soreness in the muscles of your face or around your ears?
  Do you have a history of jaw joint problems?
  Have you been treated for "TMJ"?   Do you notice clicking or popping in your jaw joint?  
  Do you clench your teeth?
  Has your jaw ever locked?   Do you have difficulty chewing or opening your mouth?  
  Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Date of Last Physical:
Patient Health:
Has there been any change in the patient's general health within the last year?     
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?     
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?     
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
  Latex   Penicillin or other antibiotics
  Sulfa drugs   Aspirin, Ibuprofen, Tylenol
  Local anesthetics   Codeine or other narcotics  
  Other:
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Heart Murmur
  Damaged or artificial heart valves
  Congenital Heart Defect
  Heart Disease
  Rheumatic Fever
  Angina
  Liver Disease / Jaundice / Hepatitis
  Kidney Disease
  Heart Attack/Stroke
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia / Blood disorder
  HIV/AIDS
  Tonsils/Adenoids Removed
  Handicaps/Disabilities
  Arthritis / Joint problems
  Large Tonsils
  Sinus trouble
  Bed wetting
  Substance abuse problem (past or present)
  Bone fractures/trauma to face/jaw
  Prosthetic joints
  Chronic fatigue
  Hospitalized for any reason
  Diabetes
  Growth Problems
  Tuberculosis or Lung Disease
  Pneumonia
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Arteriosclerosis
  Thyroid / Endocrine Problems
  Stomach ulcer or hyperacidity
  Hormone Therapy
  Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Seizures / Epilepsy / Neurological Disease
  Treated for Emotional Problems
  Asthma
  Respiratory problems / Emphysema
  Persistent swollen neck glands
  Sexually transmitted disease
  Low blood pressure
  Persistant cough
FEMALES: Are you pregnant
  Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
 
  Privacy and Consent    
Personal Information Consent Form
Expressions & Fort Orthodontics is committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible professional manner. We collect information from our patients such as names, home addresses, phone numbers, dates of birth and emergency contact information which is used for the following purposes:

• To access and maintain patient files
• Processing of patient accounts
• Claims submission to third party health benefit providers/insurance providers
• Sending patient correspondence

Contact information is disclosed to third party health providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim or insurance pre-determination on the patient’s behalf.

Financial information is collected for payment processing purposes. It is not shared with third parties without your consent, unless it is for collection purposes.

We collect information from our patients regarding health history, family health history, physical conditions, and dental treatments for diagnosing dental conditions and providing dental treatment.

Patient’s Medical Records are disclosed:

• To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement for payment of all or part of the cost of orthodontic treatment has requested us to submit a claim or insurance pre-determination on the patients’ behalf.
• To other dentists and/or dental specialists –When you are requesting a second opinion and the patient has given their consent to do so.
• To other dentists and/or dental specialists-With the patients consent, has been referred to us by to the other dentist or dental specialist for treatment.
• To other dentists and/or dental specialists-Where those dentists have asked us, with the consent of the patient, to provide a second opinion.
• To healthcare professionals such as physicians, with the consent of the patient, has been referred by us to the other health care professionals for either second opinion or treatment.
• To release information for medical –legal reports as required by law
Patient Signature (By typing my name I agree that I have read and agree to this consent form)