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 First and Last Name
*
Preferred Name
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Gender
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Age
*
Date of Birth
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School
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Grade
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Home Address
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City
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Postal
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Number of Children In Family
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Physician Name & Tel
*
Patient's Dentist
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Dentist's Tel
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May we contact your dentist to inquire about recent radiographs?
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Yes
No
Who May We Thank For Referring You?
*
Responsible Party 1 Name
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Relationship to Patient
*
Home phone
*
Cell Phone
*
Choose Best Contact Method
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Cell
Home
Occupation
*
Email
*
Responsible Party 2 Name
*
Relatioship to Patient
*
Home phone
*
Cell phone
*
Choose Best Contact Method
*
Cell
Home
Occupation
*
Email
*
Person Responsible For the Account
*
Do You Have An Insurance Plan That Covers Orthodontic Treatment?
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Yes
No
Unsure
Medical History
Pregnant
*
Yes
No
Smoker
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Yes
No
History Of Medical Condition
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Yes
No
Currently Under Any Medical Treatment?
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Yes
No
Do You Need To Be Premedicated?
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Yes
No
Do You Carry An Epi-Pen?
*
Yes
No
Is There a Heart Condition?
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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
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Has The Child Ever Been Treated For A Jaw Joint Problem, Including Surgery?
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Yes
No
Have There Been Any Injuries To The Face, Mouth Or Teeth?
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Yes
No
Please Describe
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Has The Child Ever Sucked His/Her Thumb Or Finger?
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Yes
No
Until When?
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Does The Child Have Any Speech Problems?
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Yes
No
Dose The Child Have Frequent Canker Or Cold Sores?
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Yes
No
Is The Child A Mouth Breather?
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Yes
No
Has The Child Ever Had A Previous Orthodontic Examination?
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Yes
No
Is The Child Especially Apprehensive Towards Dental Visits?
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Yes
No
Has Any Other Family Member Had Braces Or Orthodontic Treatment?
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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
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First
Last
Date
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Call 289-234-2222
info@radortho.ca
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