Virtual New Patient Consultation Form
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
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First name of Patient *
Last name of Patient *
Gender *
Age (years)
Date of Birth *
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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
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Does the patient have a major illness or serious accident? (if yes, please specify in other) *
Do any conditions exist which require special consideration? (if yes, please specify in other) *
Is the patient currently taking any medications? (if yes, please specify in other) *
Does the patient have any drug allergies or sensitivities (if yes, please specify in other) *
Is there a history of any of the following conditions pertaining to the patient? (if so, check in box) *
Required
When was the patient's last dental visit?
Has there been any treatment for:
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Has there been any significant injuries to the teeth? (if yes, please specify in other)
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Has there been any significant injuries to the jaws? (if yes, please specify in other)
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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)
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Are there any swallowing or chewing problems? (if yes, please specify in other)
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Is there a history of clenching or grinding of teeth?
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Has there been any difficulty with the jaw joint
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)
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*
Required
Please fill in the date to which this form was completed by the legal guardian or patient (if over age of 18 years) *
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