226 King Rd, Richmond Hill, ON L4E 2W1
Call 289-234-2222
Text 647-991-3300
info@radortho.ca
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Under 18 New Patient Form
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Patient's Name
*
Preferred Name
*
Gender
*
Age
*
Date of Birth
*
School/Grade
*
Home Address
*
City
*
Postal
*
Number of Children In Family
*
Physician Name & Tel
*
Patient's Dentist
*
Dentist's Tel
*
Who May We Thank For Referring You?
*
Responsible Party 1 Name
*
Relationship to Patient
*
Home Tel
*
Daytime Tel
*
Choose Best Contact Method
*
Cell
Work
Home
Occupation
*
Email
*
Responsible Party 2 Name
*
Relatioship to Patient
*
Home Tel
*
Daytime Tel
*
Choose Best Contact Method
*
Cell
Work
Home
Occupation
Email
*
Person Responsible For the Account
Do You Have An Insurance Plan That Covers Orthodontic Treatment?
Yes
No
Unsure
Medical History
Pregnant
Yes
No
Smoker
Yes
No
History Of Medical Condition
Yes
No
Currently Under Any Medical Treatment?
Yes
No
Do You Need To Be Premedicated?
Yes
No
Do You Carry An Epi-Pen?
Yes
No
Is There a Heart Condition?
Yes
No
Any Allergies?
Yes
No
If You Responded YES To Any Of The Above Questions, Please Give Pertinent Information.
Dental History
Reason For Orthodontic Consultation
*
Has The Child Ever Been Treated For A Jaw Joint Problem, Including Surgery?
*
Yes
No
Have There Been Any Injuries To The Face, Mouth Or Teeth?
*
Yes
No
Please Describe
*
Has The Child Ever Sucked His/Her Thumb Or Finger?
*
Yes
No
Until When?
*
Does The Child Have Any Speech Problems?
*
Yes
No
Dose The Child Have Frequent Canker Or Cold Sores?
*
Yes
No
Is The Child A Mouth Breather?
*
Yes
No
Has The Child Ever Had A Previous Orthodontic Examination?
*
Yes
No
Is The Child Especially Apprehensive Towards Dental Visits?
*
Yes
No
Has Any Other Family Member Had Braces Or Orthodontic Treatment?
*
Yes
No
Please Name The Family Member If Treated In Our Office
Date Of Last Dental Visit
Any Particular Concern?
Any Sports, Hobbies or Musical Instruments Played
Consent
I hereby give Rad orthodontics and/or members of her staff permission to release information concerning me or my child's dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress. I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for clinical examination.
Name
*
First
Last
Date
*
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Call 289-234-2222
info@radortho.ca