ADULT ACQUAINTANCE FORM

Please fill out the form below prior to your first visit.

    Adult Orthodontic

    Acquaintance Form

    PATIENT INFORMATION

    Name:

    Email Address:

    Date:

    Date Of Birth M/D/Y:

    Age:

    Sex:

    Home Address:

    City:

    Postal Code:

    Tel:

    Work Address:

    City:

    Postal Code:

    Tel:

    Patient’s Dentist:

    Tel:

    Family Physician:

    Tel:

    Who may we thank for referring you?

    Person Responsible for Account:

    Address:

    City:

    Postal Code:

    Tel:

    Do you have an insurance plan that covers orthodontic treatment?

    YesNo

    I authorize York Mills Orthodontics to use the e-mail address provided above for the purpose of maintaining correspondence about office events, educational information relating to orthodontics and for appointment reminders and confirmations.

    YesNo

    MEDICAL HISTORY

    HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?

    Rheumatic Fever

    YesNo

    Tuberculosis

    YesNo

    Diabetes

    YesNo

    Heart Murmur

    YesNo

    H.I.V./A.I.D.S.

    YesNo

    Kidney Disorder

    YesNo

    Mitral Valve Prolapse

    YesNo

    Hepatitis A, B, or C

    YesNo

    Liver Disease

    YesNo

    Heart Disease

    YesNo

    Sexually Transmitted Diseases

    YesNo

    Asthma

    YesNo

    Artificial Heart Valve

    YesNo

    Blood Disease

    YesNo

    Arthritis

    YesNo

    Artificial Joints

    YesNo

    Prolonged Bleeding

    YesNo

    Other

    If you responded YES to any of the above, please give pertinent information:

    Are you in good health?

    Do you have any history of major illness and/or operations?

    List any drugs or medication now being taken: Please give reasons:

    List any allergies or drug sensitivities:

    Do you have a tendency to colds?

    Sore Throats?

    Ear Infections?

    Have your tonsils or adenoids been removed?

    at what age?

    (Women) Are you pregnant?

    DENTAL HISTORY

    Have you ever been treated for a jaw joint problem, including surgery?

    YesNo

    Have there been any injuries to the face, mouth or teeth?

    YesNo

    Have you ever sucked your thumb or finger?

    YesNo

    Do you have any speech problems?

    YesNo

    Do you have frequent canker or cold sores?

    YesNo

    Are you a mouth breather?
    While Asleep:

    YesNo

    While Awake:

    YesNo

    Have you been informed of any missing or extra permanent teeth?

    YesNo

    Have you ever had a previous orthodontic examination?

    YesNo

    Has any other family member had braces or orthodontic treatments?

    YesNo

    If yes, name of family member if treated in our office:

    When did you last see your dentist?

    Reason for orthodontic consultation:

    INFORMED CONSENT: I hereby give Dr. David Morrow and/or members of his staff permission to collect all relevant personal information and to release this information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary. Such information includes x-rays and other diagnostic records which pertains to the initial condition, diagnosis, proposed treatment or treatment in progress. Financial information will be used specifically for billing purposes. We will provide the highest level of confidentiality with respect to the collection and disclosure of all of your personal information that is provided to us. Correspondence with yourself or any of the healthcare providers specifically mentioned above, may be via email or regular mail as required. By signing below, I accept the terms indicated above and I have been given the opportunity to ask all questions related to this form. I confirm that to the best of my knowledge, I have completed this form accurately, and all information recorded is correct.

    Signature:

    Date

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