ORTHODONTICS
Date
Name:
Sex: MaleFemaleSelf Identity
Date of Birth: M/D/Y / /
Age:
E-Mail:
Cell:
Home Address:
City:
Postal Code:
Tel:
Work Address:
Patient's Dentist:
Family Physician:
Who may we thank for referring you?
Person Responsible for Account:
Address:
Do you have an insurance plan that covers orthodontic treatment? YesNo
E-Mail Consent: 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 confirmation. YesNo
MEDICAL HISTORY - HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
Rheumatic Fever YesNo
Heart Murmur YesNo
Mitral Valve Prolapse YesNo
Heart Disease YesNo
Artificial Heart Valve YesNo
Artificial Joints YesNo
Tuberculosis YesNo
H.I.V./A.I.D.S. YesNo
Hepatitis A, B, or C YesNo
Sexually Transmitted Diseases YesNo
Blood Disease YesNo
Prolonged Bleeding YesNo
Diabetes YesNo
Kidney Disorder YesNo
Liver Disease YesNo
Asthma YesNo
Arthritis 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?
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 Until what age?
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 me or my child's 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 personal information regarding you and/or your child 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
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