New Patient Form "*" indicates required fields Patient InformationDate* Patient's Name* First MI Last Patient's Date of Birth* Age*Sex Female Male Other Patient 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 Other Is the patient under the age of 18?Selecting yes will require you to fill out a 'Parent Information' section Yes No Parent InformationPatient lives with: Mother Father Both Parents Other Person 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 Insurance Our 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 Unsure Insurance InformationInsurance CompanyInsurance CompanyPolicy #Policy #ID #ID #Subscriber's NameSubscriber's Name First Last Subscriber's Date of Birth Subscriber's Date of BirthDo you receive funding through: Indian Affairs Social Assistance A.I.S.H Ward of Government Cleft Plate Clinic Dental HistoryReason for consultation (chief concern)Is the patient happy with his/her smile? Yes No Unsure If not, what would they change?Has the patient ever had or been evaluated for orthodontic treatment? Yes No If yes, when?Does the patient want tratment? Yes No Dental HistoryHas the patient ever experienced problems with their jaws (TMJ)? Yes No If yes, please specifyHave there been any injuries to the face, mouth, teeth, chin? Yes No If 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 Biting Dental HistoryDoes the patient see dentist regularly? Yes No How 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 Fair Is the patient currently under care of a Physician? Yes No If yes, please explainDoes the patient require antibiotics before dental treatment? Yes No If yes, please explain Medical HistoryIs the patient taking any prescription/over the counter drugs? Yes No If yes, please list allDoes the patient have any allergies? Yes No If yes, please list allDo you use tobacco (smoking or chewing)? Yes No For females: Has the patient started her menstrual cycle? Yes No Unsure For females: Is the patient pregnant? Yes No Unsure Medical 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 Ulcers Hepatitis, TypeIf yes to any above, please explainDescribe any other medical conditions not listed Signature I 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* Select Signature StyleMerriweatherDancing ScriptBirthstoneFull Name* Δ
