New Patient Walnut Grove Orthodontist Call (604) 888-3450 Book An Appointment New Patient Form New Patient Date * Age * Gender * M F Parent/Guardians name * Patient's First Name * Patient's Last Name * Patient's Date of Birth * Address * City * Postal Code * Home # Cell # Work # Email Address * Consent I give consent to receiving correspondence emails and/ or SMS from Walnut Grove Orthodontist Family Dentist * Tel * Whom may we thank for referring you? In Case of Emergency Notify * Tel * Relationship * Person Responsible For Payments * Relationship * Family Physician * Tel * Dental Insurance * Yes No Plan #1 (Primary) Insured Name Insured Date Of Birth Insurance Company Group/Policy/Cert # I.D. # Plan #2 (Secondary) Insured Name Insured Date Of Birth Insurance Company Group/Policy/Cert # I.D. # Dental History Have you had regular dental visits in the past? * Yes No Do you have clicking/popping sound from your jaw? * Yes No Are you currently having any dental pain? * Yes No Are you aware of any sores or lumps in your mouth? * Yes No Do your gums bleed when you brush/floss? * Yes No Are you aware of clenching or grinding your teeth? * Yes No Have you ever had orthodontic treatment before? * Yes No How often do you brush your teeth? * Have you ever been treated for periodontal (gum) disease * Yes No How often do you floss your teeth? * Medical History Have you had any of the following? Heart Trouble High Blood Pressure Rheumatic Fever Autism Kidney Trouble Heart Murmur Severe Allergies ADHD Arthritis Diabetes Hay Fever Liver Disease Sinus Trouble AIDS/HIV + Asthma Blood Disorder Tuberculosis Digestive Disorder Hepatitis A, B, C Thyroid Disorder Epilepsy Cancer Stroke Have you been diagnosed with a spectrum disorder? * Yes No Have you ever been a patient in hospital or under the care of a physician during the past 2 years? * Yes No Have you taken any kind of drugs or medicine in the past 2 years? * Yes No Are you allergic to latex, penicillin or any other drugs or medications? * Yes No Do you ever have chest pains? * Yes No Have you ever experienced unexplained shortness of breath? * Yes No Have you ever experienced excessive bleeding that required special treatment? * Yes No Have you ever had a serious illness? * Yes No Are you pregnant now? * Yes No Do you smoke (tobacco, marijuana, other) How many per day? * How long have you smoked for? * Consent of Treatment Comments/Anything else we should know (e.g. elaborate on any “ Yes” responses or any other health concerns ): Date * I certify that the above information is correct to the best of my knowledge I authorize the doctor upon consultation and direct consent from patient/parent/guardian to perform diagnostic procedures, treatment and medication in connection with the patients dental needs I understand the responsibility for payments of dental services, including insurance or otherwise, is due and payable at the time services are rendered and despite any dental insurance. I am ultimately responsible for any fees withheld by the insurance company Signature * Clear Are you a: * Patient Parent Guardian If you are human, leave this field blank. Submit
