Orillia Orthodontics - New Patient Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form should be filled out by the "patient" if the patient is over the age of 18 years. If the "patient" is under the age of 18 years, this form should be filled out by the legal guardian

First Name *

Last Name *

Gender *

Male

Female

Non-binary

If none of the above apply, please write below what the new patient identifies as...

Other:

What pronouns are preferred by the new patient

He/him

She/her

They/them

Clear selection

Age (years)

Date of Birth *

YYYY

Address of Patient (Street, RR, City, Postal Code) *

Email Address *

Name of the legal guardian of the patient *

Name of person responsible for account *

Phone Number of Patient

Mother's Name and Phone Number

Father's Name and Phone Number

Name of Patient's Dentist

Do you have orthodontic insurance coverage

Yes

Maybe

Clear selection

Does the patient have a major illness or serious accident? (if yes, please specify in other)

Other:

Clear selection

Do any conditions exist which require special consideration? (if yes, please specify in other) *

Other:

Is the patient currently taking any medications? (if yes, please specify in other) *

Other:

Does the patient have any drug allergies or sensitivities (if yes, please specify in other) *

Other:

Is there a history of any of the following conditions pertaining to the patient? (if so, check in box) *

Arthritis

Asthma

HIV

Bleeding disorder

Diabetes

Pneumonia

Herpes

Venereal disease

Kidney ailment

Epilepsy

Bone disorder

Dizziness

Heart murmur

Ulcers

Rheumatic fever

Jaundice

Migraines

Hormonal disorders

Fainting

Heart disease

Cancer

Liver disorders

Tuberculosis

Muscular disorders

None of the above

Other:

Required

When was the patient's last dental visit?

Has there been any treatment for:

Root canals

Gum disease

Large cavities

Clear selection

Has there been any significant injuries to the teeth? (if yes, please specify in other)

Other:

Clear selection

Has there been any significant injuries to the jaws? (if yes, please specify in other)

Other:

Clear selection

Do any teeth cause pain or ache at present?

Is there a history of finger or thumb sucking? (if yes, please specify in other - age stopped or persistant)

Other:

Clear selection

Are there any swallowing or chewing problems? (if yes, please specify in other)

Other:

Clear selection

Is there a history of clenching or grinding of teeth?

Yes

Clear selection

Has there been any difficulty with the jaw joint

Pain?

Clicking?

Opening/Closing?

Other:

What is the reason for seeking orthodontic treatment?

Has the patient had a previous orthodontic examination? (if yes, please specify in other the date and name of orthodontist)

Other:

Clear selection

I, the legal guardian or patient (if over age of 18 years), hereby state that to the best of my knowledge the above information is true and correct and I agree to allow Dr. Stirling/Dr. MacGregor to contact my family dentist and other health care professionals as required to permit proper treatment.

Required

Please fill in the date to which this form was completed by the legal guardian or patient (if over age of 18 years) *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms