Download New Patient Form | Child

Today’s Date (mm/dd/yyyy):
DEMOGRAPHIC INFORMATION
Patient’s Name (Last, First, Initial):
Address:City:Postal Code:
Date of Birth (mm/dd/yyyy):
Age:
Gender: q Male q Female
Patient’s Dentist: Mother’s Name: Home Telephone: Referred by:
Mother’s Work Telephone:
Cell#:
Mother’s Address:Mother’s Email:
Father’s Name:
Father’s Work Telephone:
Cell#:
Father’s Address:Father’s Email:
q I agree to receive email messages from Icon Orthodontics which may include appointment reminders, newsletters, upcoming events and
important notifications. You can withdraw your consent at any time.
MEDICAL HISTORY
Patient’s Physician:
Is patient under care of physician now? q Yes q No
If yes, for what reason:
Is patient considered to be in good health? q Yes q No
Is patient taking any medications presently? q Yes q No If yes, please list:
Has patient ever had serious illness or been hospitalized? q Yes q No If yes, describe:
Does patient have allergies? q Yes q No If yes, specify:
Has patient had tonsils removed? q Yes q No
Has patient ever had or been treated for (check all that apply):
q Diabetes
q Bone disorder
q Anemia
q Kidney disease
q Rheumatic fever
q Pneumonia
q Liver disease
q Hepatitis
q Gland problems
q AIDS or HIV positive
q Heart trouble/murmur
q Arthritis
q Asthma
q Prolonged bleeding
q Nervous disorder
q Epilepsy
Alberta Health requires screening for the following:
q Frequent Diarrhea
q Skin Rash
q Persistent Cough
Females: Has menstruation started? q Yes q No Is patient pregnant? q Yes q No
Males: Has voice changed? q Yes q No
DENTAL HISTORY
Why is patient seeking orthodontic treatment? q Appearance q Bite problems q Dentist referral Other, specify:
Date of last dental examination (mm/dd/yyyy):
Did patient have x-rays? q Yes q No q unsure
Has patient ever had (check all that apply): q Fillings q Crowns/bridges q Implants q Extractions q Spacers/retainers q Orthodontics
Is patient nervous about seeing the Dentist? q Yes q No Has patient had bad dental experiences? q Yes q No
How often does patient brush?
How often does patient floss?
Does patient clench or grind teeth? q Yes q No
Has patient had injury to face/jaws/teeth? q Yes q No If yes, describe:
Has patient ever sucked thumb/finger/lip? q Yes q No Have siblings had orthodontic treatment? q Yes q No
If so, describe:
Have the patient’s teeth erupted? q Early q Average q Late
TMJ HISTORY
Does patient have frequent headaches? q Yes q No If yes, describe:
Has patient noticed jaw joint noises? q Yes q No If yes: q Previously q Currently
Type of noise: q clicking q left q right q popping q left q right q grating q left q right
Has patient had jaw joint pain? q Yes q No Has patient ever had jaw “lock”? q Yes q No
Has patient had treatment for jaw joint pain? q Yes q No Has patient had jaw joint x-rays for jaw joint problems? q Yes q No
PATIENT CONSENT
I,
(parent/guardian) for
(patient)
do hereby authorize the performance of required dental and orthodontic services by the Orthodontist of Icon Services, their assistants or designees.
I further authorize the administration of those dental and orthodontic treatments as are deemed necessary by the Orthodontist.
I accept full responsibility for all financial agreements.
I hereby sign on the patient’s behalf as legal guardian.
Parent/GuardianRelationship to patient
WitnessDate (mm/dd/yyyy)
INSURANCE INFORMATION
Do you have coverage for orthodontic treatment? q Yes q No
Additional Insurance? q Yes q No
Insurance One:
Name of Insured:Date of Birth (mm/dd/yyyy):
Employer:
Name of Insurance Company:
Policy No.:ID No.:
Insurance Two:
Name of Insured:Date of Birth (mm/dd/yyyy):
Employer:
Name of Insurance Company:
Policy No.:ID No.:
PERSONAL INFORMATION CONSENT
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and
professional manner. As a requirement of the federal and provincial governing bodies we have privacy policies in place. If you would like further
information on the privacy policies of this office please ask one of our staff and we would be happy to answer any questions you may have.
I consent to the collection, use and disclosure of personal information for
Signature of Parent/GuardianDate (mm/dd/yyyy)
Print Name
(patient name) as set out above.