Medical Information Record – Child

You may complete the Patient History form below and submit the data online. You can also download and print the following 2 PDF files and bring the completed form to your first visit: The forms are compliant with the Personal Information Protection and Electronic Documents Act (PIPEDA). Please fill out all items to your best knowledge. Fields marked with an asterisk (*) are required.

    CHILD ORTHODONTIC PATIENT INFORMATION

  • MaleFemaleX

    PARENT/GUARDIAN INFORMATION

  • DOES PATIENT HAVE ORTHODONTIC INSURANCE COVERAGE? YesNo

    PRIMARY INSURANCE

    SECONDARY INSURANCE

    MEDICAL HISTORY

    Has your child ever been diagnosed with the following?

  • DiabetesHeart ConditionCancerDrug/Alcohol AbuseTuberculosisHepatitisHeart MurmurEmotional ProblemsAids/HIV positiveEpilepsyRadiation TreatmentSpeech/Hearing ProblemsLung DisordersDifficulty BreathingSinus ProblemsVision ProblemsAnemiaPsychiatric Problems
  • Are you in good health? YesNo
  • Are you taking any medications (include over-the-counter) YesNo
  • Have you ever been diagnosed with Osteoporosis, bone density concerns or taken Bisphosphonates?
    YesNo
  • List any daily medications you are presently taking:
  • Have adenoid and/or tonsils been removed? YesNo

    Are you allergic to any of the following?

  • AnestheticsAspirinAmoxicillinCodeineCyclosporinsErythromycinLatexNickelPenicillinSulfa DrugsTetracyclineOTHER
  • Please List any other medicine or material you may be allergic to:

    DENTAL HISTORY

  • Have had complications following dental treatment? YesNo
  • Ever injured any teeth? YesNo
  • Ever injured jaw or face? YesNo
  • Currently have cavities/toothaches that need treatment? YesNo
  • Needs to be pre-medication before dental treatment? YesNo

    AUTHORIZATION

    I have examined the above information and it is true and correct.