New Patient Form"*" indicates required fieldsPatient InformationDate* MM slash DD slash YYYY Patient's Name* First MI Last Patient's Date of Birth* MM slash DD slash YYYY Age*Sex Female Male OtherPatient InformationAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone #Cell PhoneHome PhoneHome PhoneWork PhoneWork PhoneOccupationEmail* Patient InformationDentist's Name First Last Family members seen by usWhom may we thank for referring you? Dentist Friend Family Website OtherIs the patient under the age of 18?Selecting yes will require you to fill out a 'Parent Information' section Yes NoParent InformationPatient lives with: Mother Father Both Parents OtherPerson responsible for the account First Last Relation to patientRelation to patientPhone #Cell PhoneHome PhoneHome PhoneWork PhoneWork PhoneAddress (if different from the patient) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Mother's InformationMother's Name First Last Address (if different from the patient) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone #Cell PhoneMother : Home PhoneHome PhoneMother : Work PhoneWork PhoneOccupationEmail Father's InformationFather's Name First Last Address (if different from the patient) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone #Cell PhoneFather : Home PhoneHome PhoneFather : Work PhoneWork PhoneOccupationEmail InsuranceOur office charges the patient/parent/guardian directly for all professional services rendered. We will assist you in completing the necessary claim forms, so that you can receive the reimbursement to which you are entitled under your policy.Do you have orthodontic coverage? Yes No UnsureInsurance InformationInsurance CompanyInsurance CompanyPolicy #Policy #ID #ID #Subscriber's NameSubscriber's Name First Last Subscriber's Date of Birth MM slash DD slash YYYY Subscriber's Date of BirthDo you receive funding through: Indian Affairs Social Assistance A.I.S.H Ward of Government Cleft Plate ClinicDental HistoryReason for consultation (chief concern)Is the patient happy with his/her smile? Yes No UnsureIf not, what would they change?Has the patient ever had or been evaluated for orthodontic treatment? Yes NoIf yes, when?Does the patient want tratment? Yes NoDental HistoryHas the patient ever experienced problems with their jaws (TMJ)? Yes NoIf yes, please specifyHave there been any injuries to the face, mouth, teeth, chin? Yes NoIf yes, please specifyHas the patient had or presently have any of the following habits: Thumb/ finger sucking Lip Biting Snoring Grinding Clenching Chronic Mouth Breathing Speech Problems Tongue Thrusting Chewing/Eating Problems Sinus Problems Nail BitingDental HistoryDoes the patient see dentist regularly? Yes NoHow often does patient brush?How often does patient floss?Medical HistoryPhysician's InformationPhysician's NamePhysician's Name First Last Physician's Phone #Physician's Phone #Patient's current health is: Good FairIs the patient currently under care of a Physician? Yes NoIf yes, please explainDoes the patient require antibiotics before dental treatment? Yes NoIf yes, please explainMedical HistoryIs the patient taking any prescription/over the counter drugs? Yes NoIf yes, please list allDoes the patient have any allergies? Yes NoIf yes, please list allDo you use tobacco (smoking or chewing)? Yes NoFor females: Has the patient started her menstrual cycle? Yes No UnsureFor females: Is the patient pregnant? Yes No UnsureMedical HistoryHas the patient had or presently have any of the following conditions: Anemia/Blood transfusion Hemophilia AIDS/HIV Alcohol/Drug Abuse Arthritis Artificial joints Asthma Cancer/Chemotherapy Radiation Treatment Colitis/Crohns Hepatitis Congenital heart defect Mitral Valve Prolapse Pacemaker/Heart Attack/Stroke Diabetes Emotional/Psychiatric Problems Emphysema Epilepsy/Seizures/Fainting Fetal Alcohol Syndrome Frequent Headaches Hay Fever Herpes (cold sores) High Blood Pressure Low Blood Pressure Hospitalized for any reason Kidney Problems Liver Disease Lupus Shingles Thyroid Problems Tuberculosis UlcersHepatitis, TypeIf yes to any above, please explainDescribe any other medical conditions not listedSignatureI understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in strictest confidence and that it is my responsibility to inform this office of any changes in my medical statusDate* MM slash DD slash YYYY Select Signature StyleMerriweatherDancing ScriptBirthstoneFull Name*CAPTCHAΔ
