About
What We Do
New Patients
Invisalign
Contact Us
Book Now in CP
Book Now in Arnprior
Dentist Referral
Back
Our Orthodontists
Our Team Members
Office Tour
Back
Treatment Options
Invisalign
LightForce 3D Braces
Early Intervention
Life with Braces
Retainers
Appliance Videos
Virtual Visit Photos
Back
What to Expect
Affordability & Insurance
FAQ's
New Patient Forms
Dentist Referral Form
About
Our Orthodontists
Our Team Members
Office Tour
What We Do
Treatment Options
Invisalign
LightForce 3D Braces
Early Intervention
Life with Braces
Retainers
Appliance Videos
Virtual Visit Photos
New Patients
What to Expect
Affordability & Insurance
FAQ's
New Patient Forms
Dentist Referral Form
Invisalign
Contact Us
Carleton Place & Arnprior's Certified Specialists in Orthodontics
Book Now in CP
Book Now in Arnprior
Dentist Referral
New Patient Form for Adults
Name
*
First Name
Last Name
Nickname
Gender
*
Male
Female
Other
Birthdate
*
MM
DD
YYYY
Street Address
*
City/Town
Postal Code
Home Phone Number
(###)
###
####
Work Phone Number
(###)
###
####
Cell Phone Number
(###)
###
####
Preferred Phone Number
Home
Work
Cell
Email Address
*
Marital Status
Occupation
Employer
Spouse/Partner's Name
What concerns you about your teeth?
*
Who may we thank you referring you to our office?
*
Primary Insurance Information
If you have dental insurance, providing the following information will allow us to enter it into the insurance forms for your convenience.
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
MM
DD
YYYY
Insurance Company Name
Policy Holder's Member ID #
Policy Holder's Group #
Secondary Insurance Information
If you have dental insurance, providing the following information will allow us to enter it into the insurance forms for your convenience.
Secondary Policy Holder's Name
First Name
Last Name
Secondary Policy Holder's Date of Birth
MM
DD
YYYY
Insurance Company Name
Secondary Policy Holder's Member ID #
Secondary Policy Holder's Group #
For Females Only
Do you have regular menstrual cycles?
Yes
No
Unsure
Have you experienced menopause?
No
Yes
Unsure
Is there a possibility that you could be pregnant?
No
Yes
Are you presently nursing?
No
Yes
Medical & Dental History
Who is your general dentist?
*
If none, please write "None".
Have you seen your dentist within the last 9 months?
*
Yes
No
Is there any planned work to be done at the general dentist's office that has not yet been done? (Ex: Fillings/Cavities, Crowns, Etc.)
*
If none, please write "None".
Have you had any of the following dental concerns?
*
Please select any that apply.
NO DENTAL CONCERNS
Tooth pain
Tooth injuries due to accident(s)
Thumb/finger sucking beyond age 6
Breathing through mouth instead of nose
Speech issues
Clenching and/or grinding teeth
Pain and/or clicking on opening/closing mouth
Severe head or neck injuries
Missing adult teeth
Extra teeth
History of teeth removed by dentist
Previous orthodontic consult or treatment
Similar condition in the family
Difficulty chewing or swallowing
Other
Have you ever had any of the following medical concerns?
*
Please select any that apply.
NO MEDICAL CONCERNS
Abnormal Bleeding
Anemia
Artificial Bones/Joints/Valves
Arthritis
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defects
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy/Seizures/Fainting
Fever Blisters/Herpes
Glaucoma
Heart Attack/Stroke
Heart Murmur
Heart Surgery/Pacemaker
Hepatitis
High/Low Blood Pressure
HIV+/AIDS
Hospitalized For Any Reason
Kidney Problems
Mitral Valve Prolapse
Mental Health Illness
Radiation Treatment
Rheumatic/Scarlet Fever
Severe/Frequent Headaches or Neck Pain
Sleep Apnea
Shingles
Sickle Cell Disease/Trait
Sinus Problems
Tuberculosis
Ulcers/Colitis
Other
Are you taking any medication?
*
No
Yes
Please indicate type, dosage, and reason for any medications being taken.
Have you or has anyone in your family had osteoporosis?
No
Yes
Unsure
Have you ever taken any type of medication for low bone density or osteoporosis (excluding calcium supplements)?
*
No
Yes
Please elaborate on any medical or dental issues you may have.
Do you have any known allergies?
*
No
Yes - please list below
Please list all allergies if applicable.
Has any other member of the family had orthodontic treatment? If so, whom?
Has any member of the family required jaw surgery to correct their bite? If yes, please describe.
*
Is there anything else that you'd like to share with us?
We will be asking you to sign this form electronically at your consultation appointment.
Thank you for submitting your information! We look forward to meeting you soon!
