CHILD ACQUAINTANCE FORM

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

Child Orthodontic
Acquaintance Form
PATIENT INFORMATION
Name:
Email Address:
Date:
Date of Birth:
Age:
Sex:
School:
Grade:
Home Address:
City:
Postal Code:
Tel:
Number of Children in Family:
Age & Names of Other Children:
Patient’s Dentist:
Tel:
Family Physician:
Tel:
Who may we thank for referring you?
Mother’s Name (if applicable):
Home Tel:
Work Tel:
Father’s Name (if applicable):
Home Tel:
Work Tel:
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:
Is the child in good health?
Does the child 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
Does the child have a tendency to colds?
Sore Throats?
Ear Infections?
Have tonsils or adenoids been removed?
at what age?
Has the patient reached puberty? Girls-Has menstruation started?
YesNo
Boys-Has voice changed yet?
YesNo
DENTAL HISTORY
Has the child ever been treated for a jaw joint problem, including surgery?
YesNo
Have there been any injuries to the face, mouth or teeth?
YesNo
Has the child ever sucked his/her thumb or finger?
YesNo
Does the child have any speech problems?
YesNo
Does the child have frequent canker or cold sores?
YesNo
Is the child a mouth breather?
While Asleep:
YesNo
While Awake:
YesNo
Have you been informed of any missing or extra permanent teeth ?
YesNo
Has the child ever had a previous orthodontic examination?
YesNo
Is the child especially apprehensive toward dental visits?
YesNo
Does the child want orthodontic treatment?
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 the child last see the family dentist?
List any sports, hobbies or musical instruments
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.

Signature of Parent or Guardian:
Date

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