PATIENT INFORMATION |
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Email Address |
: [email-788] |
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Date of Birth |
: [date-20003] |
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Home Address |
: [text-9007] |
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Postal Code |
: [text-9009] |
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Number of Children in Family |
: [text-9011] |
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Age & Names of Other Children |
: [text-9012] |
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Patient’s Dentist |
: [text-9013] |
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Family Physician |
: [text-9015] |
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Who may we thank for referring you? |
: [text-9017] |
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Mother’s Name (if applicable) |
: [text-9018] |
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Father’s Name (if applicable) |
: [text-9021] |
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Person Responsible for Account |
: [text-9024] |
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Postal Code |
: [text-9027] |
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Do you have an insurance plan that covers orthodontic treatment? |
: [checkbox-1600] |
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. |
: [checkbox-1709] |
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MEDICAL HISTORY - HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING? |
Rheumatic Fever |
: [checkbox-1600] |
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Tuberculosis |
: [checkbox-1601] |
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Diabetes |
: [checkbox-1602] |
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Heart Murmur |
: [checkbox-1603] |
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H.I.V./A.I.D.S. |
: [checkbox-1604] |
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Kidney Disorder |
: [checkbox-1605] |
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Mitral Valve Prolapse |
: [checkbox-1606] |
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Hepatitis A, B, or C |
: [checkbox-1607] |
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Liver Disease |
: [checkbox-1608] |
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Heart Disease |
: [checkbox-1609] |
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Sexually Transmitted Diseases |
: [checkbox-1611] |
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Artificial Heart Valve |
: [checkbox-1613] |
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Blood Disease |
: [checkbox-1614] |
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Arthritis |
: [checkbox-1615] |
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Artificial Joints |
: [checkbox-1616] |
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Prolonged Bleeding |
: [checkbox-1617] |
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If you responded YES to any of the above, please give pertinent information |
: [text-9030] |
Is the child in good health? |
: [text-9031] |
Does the child have any history of major illness and/or operations? |
: [text-9032] |
List any drugs or medication now being taken: Please give reasons |
: [text-9033] |
List any allergies or drug sensitivities |
: [text-9034] |
Does the child have a tendency to colds? |
: [text-9035] |
Sore Throats? |
: [text-9036] |
Ear Infections? |
: [text-9037] |
Have tonsils or adenoids been removed? |
: [text-9038] |
at what age? |
: [text-9039] |
Has the patient reached puberty? Girls-Has menstruation started? |
: [checkbox-1633] |
Boys-Has voice changed yet? |
: [checkbox-1634] |
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DENTAL HISTORY |
Has the child ever been treated for a jaw joint problem, including surgery? |
: [checkbox-1618] |
Have there been any injuries to the face, mouth or teeth? |
: [checkbox-1619] |
Has the child ever sucked his/her thumb or finger? |
: [checkbox-1620] |
Does the child have any speech problems? |
: [checkbox-1621] |
Does the child have frequent canker or cold sores? |
: [checkbox-1622] |
Is the child a mouth breather? |
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While Asleep |
: [checkbox-1623] |
While Awake |
: [checkbox-1624] |
Have you been informed of any missing or extra permanent teeth? |
: [checkbox-1625] |
Has the child ever had a previous orthodontic examination? |
: [checkbox-1626] |
Is the child especially apprehensive toward dental visits? |
: [checkbox-1627] |
Does the child want orthodontic treatment? |
: [checkbox-1631] |
Has any other family member had braces or orthodontic treatments? |
: [checkbox-1632] |
If yes, name of family member if treated in our office |
: [text-9040] |
When did you last see your dentist? |
: [text-9041] |
List any sports, hobbies or musical instrument |
: [text-9042] |
Reason for orthodontic consultation |
: [text-9043] |
INFORMED CONSENT |
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Today's Date |
: [date-20004] |
Patient or Guardian Signature: |
:  |
IP |
: [_remote_ip] |
Date/Time |
: [_date] [_time] |