Patient's Name
*
First Name
Middle Name
Last Name
Gender
*
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Birth Date
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Confirmation Email
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School
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*
Please Select
Father
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Spouse
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Responsible Party's Name
*
First Name
Middle Name
Last Name
Address
*
Apt / Street Number
Street Address Line 2
City
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Postal / Zip Code
Do you have any more kids (under 18 years old) accompanying you for the same appointment?
*
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Does the patient has any more siblings (under 18 years) accompanying for the same appointment?
*
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How many
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Residence Tel.
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Referral By
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Type option 1
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Dentist Name
*
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Child Medical History Form
Have You Or Any Other Member Of Your Family had Orthodontic Treatment?
Yes
No
Were they treated at Sudbury Orthodontics?
Yes
No
Please Specify Their Name
What Orthodontic Concerns Do You Have About Your Child's Teeth Or Mouth?
*
Has Your Child Suffered Any Severe Accidents Involving:
Face
Teeth
Jaws
None
Does Your Child Have Allergies Related To:
*
Asthma
Hayfever
Drugs
Latex
Other
None
Please Specify
Does Your Child Have Difficulty Breathing Through His/Her Nose?
Yes
No
Does Your Child Have Any Oral Habits Such As:
Thumb Sucking
Finger Sucking
Tongue Thrusting
Other
None
Please Specify
Have Your Child's Tonsils And/Or Adenoids Been Removed?
Yes
No
If So, When?
Has Your Child Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain
Is Your Child Presently In Good General Health?
Yes
No
Is Your Child Presently Under A Physician's Care For Anything That Is Other Than Routine?
Yes
No
Physician's Name
For What Reason?
Is Your Child Currently Taking Any Medication?
Yes
No
Please List.
Has Your Child Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Has Your Child Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List
Has Your Child Experienced Any Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
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Next
Adult Medical History
Have You Or Any Other Member Of Your Family had Orthodontic Treatment?
Yes
No
Were they treated at Sudbury Orthodontics?
Yes
No
Please specify their name
What Are Your Concerns With Your Smile Or Bite?
*
Have You Suffered Any Severe Accidents Involving:
Face
Teeth
Jaw
None
Do You Have Allergies Related To:
*
Asthma
Drugs
Hayfever
Latex
Other
None
Please Specify
Do You Have Difficulty Breathing Through Your Nose?
Yes
No
Do You Have Or Did You Ever Have Any Oral Habits Such As
Thumb Sucking
Finger Sucking
Tongue Thrusting
Clenching / Grinding
Other
None
Please List
Have Your Tonsils And/Or Adenoids Been Removed?
Yes
No
Have You Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain.
Are You Presently In Good General Health?
Yes
No
Are You Presently Under A Physician's Care?
Yes
No
Physician's Name
For What Reason?
Are You Currently Taking Any Medication?
Yes
No
Please List.
Have You Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Have You Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List.
Have You Experienced Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
Back
Next
Family Member 1 - Medical History
Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
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Month
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1933
1932
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1930
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1926
1925
1924
1923
1922
1921
1920
Year
Age
*
Have You Or Any Other Member Of Your Family had Orthodontic Treatment?
Yes
No
Were they treated at Sudbury Orthodontics?
Yes
No
Please Specify Their Name
What Orthodontic Concerns Do You Have About Your Child's Teeth Or Mouth?
*
Has Your Child Suffered Any Severe Accidents Involving:
Face
Teeth
Jaws
None
Does Your Child Have Allergies Related To:
*
Asthma
Hayfever
Drugs
Latex
Other
None
Please Specify
Does Your Child Have Difficulty Breathing Through His/Her Nose?
Yes
No
Does Your Child Have Any Oral Habits Such As:
Thumb Sucking
Finger Sucking
Tongue Thrusting
Other
None
Please Specify
Have Your Child's Tonsils And/Or Adenoids Been Removed?
Yes
No
If So, When?
Has Your Child Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain
Is Your Child Presently In Good General Health?
Yes
No
Is Your Child Presently Under A Physician's Care For Anything That Is Other Than Routine?
Yes
No
Physician's Name
For What Reason?
Is Your Child Currently Taking Any Medication?
Yes
No
Please List.
Has Your Child Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Has Your Child Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List
Has Your Child Experienced Any Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
Family Member 2 - Medical History
Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
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September
October
November
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Month
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31
Day
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1972
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1951
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1949
1948
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1942
1941
1940
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
*
Have You Or Any Other Member Of Your Family had Orthodontic Treatment?
Yes
No
Were they treated at Sudbury Orthodontics?
Yes
No
Please Specify Their Name
What Orthodontic Concerns Do You Have About Your Child's Teeth Or Mouth?
*
Has Your Child Suffered Any Severe Accidents Involving:
Face
Teeth
Jaws
None
Does Your Child Have Allergies Related To:
*
Asthma
Hayfever
Drugs
Latex
Other
None
Please Specify
Does Your Child Have Difficulty Breathing Through His/Her Nose?
Yes
No
Does Your Child Have Any Oral Habits Such As:
Thumb Sucking
Finger Sucking
Tongue Thrusting
Other
None
Please Specify
Have Your Child's Tonsils And/Or Adenoids Been Removed?
Yes
No
If So, When?
Has Your Child Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain
Is Your Child Presently In Good General Health?
Yes
No
Is Your Child Presently Under A Physician's Care For Anything That Is Other Than Routine?
Yes
No
Physician's Name
For What Reason?
Is Your Child Currently Taking Any Medication?
Yes
No
Please List.
Has Your Child Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Has Your Child Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List
Has Your Child Experienced Any Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
Family Member 3 - Medical History
Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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18
19
20
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22
23
24
25
26
27
28
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30
31
Day
Please select a year
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2023
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2021
2020
2019
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
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1963
1962
1961
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1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
*
Have You Or Any Other Member Of Your Family had Orthodontic Treatment?
Yes
No
Were they treated at Sudbury Orthodontics?
Yes
No
Please Specify Their Name
What Orthodontic Concerns Do You Have About Your Child's Teeth Or Mouth?
*
Has Your Child Suffered Any Severe Accidents Involving:
Face
Teeth
Jaws
None
Does Your Child Have Allergies Related To:
*
Asthma
Hayfever
Drugs
Latex
Other
None
Please Specify
Does Your Child Have Difficulty Breathing Through His/Her Nose?
Yes
No
Does Your Child Have Any Oral Habits Such As:
Thumb Sucking
Finger Sucking
Tongue Thrusting
Other
None
Please Specify
Have Your Child's Tonsils And/Or Adenoids Been Removed?
Yes
No
If So, When?
Has Your Child Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain
Is Your Child Presently In Good General Health?
Yes
No
Is Your Child Presently Under A Physician's Care For Anything That Is Other Than Routine?
Yes
No
Physician's Name
For What Reason?
Is Your Child Currently Taking Any Medication?
Yes
No
Please List.
Has Your Child Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Has Your Child Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List
Has Your Child Experienced Any Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
Back
Next
Insurance Information
Do you have insurance?
*
Yes
No
Please specify
*
Primary Insurance
Secondary Insurance
Primary Insurance
Primary Insurance
Insurance Holder Date of Birth
*
Please select a month
January
February
March
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June
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Month
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31
Day
Please select a year
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1996
1995
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1993
1992
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1988
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1986
1985
1984
1983
1982
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1976
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1957
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1948
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1936
1935
1934
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1932
1931
1930
1929
1928
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1926
1925
1924
1923
1922
1921
1920
Year
Insurance Holder's Relationship To The Patient
*
Employer Name
*
Insurance Holder's Address
*
Same as Patient's Address
Different Address
Insurance Holder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select
*
Take a picture (front & back) or upload insurance card
Enter Insurance Details
Take a picture (front & back) or upload insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Plan Holder Name
*
First Name
Last Name
Insurance Company Name
*
Group Number
*
Certificate Number
*
Secondary Insurance
Secondary Insurance
Insurance Holder Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
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31
Day
Please select a year
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2004
2003
2002
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2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
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1978
1977
1976
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1970
1969
1968
1967
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1965
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1961
1960
1959
1958
1957
1956
1955
1954
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1952
1951
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1948
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1942
1941
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1939
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1936
1935
1934
1933
1932
1931
1930
1929
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1926
1925
1924
1923
1922
1921
1920
Year
Insurance Holder's Relationship To The Patient
*
Employer Name
*
Insurance Holder's Address
*
Same As Patient's Address
Different Address
Insurance Holder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select
*
Take a picture (front & back) or upload insurance card
Enter Insurance Details
Take a picture (front & back) or upload insurance card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Plan Holder Name
*
First Name
Last Name
Insurance Company Name
*
Group Number
*
Certificate Number
*
Additional Information
Does the patient qualify under the following programs?
*
NIHB / Jordan's Principle
Ontario Disability Act
Ontario Workers
CAS
None
Other
Back
Next
During the orthodontic consultation, I consent to the making of diagnostic records, including x-rays, photos, and dental scans.
Yes
No
Please specify your concern.
Our Office Complies With Privacy Legislation, The Regulations Of The Royal College Of Dental Surgeons Of Ontario And The Law. Please Be Assured That Every Team Member In Our Office Is Committed To Protecting Your Personal Health Information. The Above Medical History Is Correct To The Best Of My Knowledge. I Authorize My Doctor To Consult With And/Or Send Reports And/Or Dental Practitioners As It Relates To Orthodontic Treatment.
*
I Understand
Patient's Signature
*
Patient's Full Name
*
First Name
Middle Name
Last Name
Responsible Party's Signature
*
Responsible Party's Full Name
*
First Name
Middle Name
Last Name
Submit
Should be Empty: