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 Children
Patient's Name
*
First Name
Last Name
Patient's Nickname
Patient's Gender
*
Male
Female
Other
Patient's Birthdate
*
MM
DD
YYYY
Street Address
*
City/Town
*
Postal Code
*
Patient's Cell Phone Number (if Applicable)
(###)
###
####
Patient's Email Address (if Applicable)
Patient's School
Patient's Hobbies
What concerns you about your child's teeth?
*
Who may we thank you referring you to our office?
*
Billing Party
The billing party is the person who will be responsible for and who should be contacted regarding payments. This is most commonly a parent or guardian.
Billing Party's Name
*
First Name
Last Name
Billing Party's Gender
*
Male
Female
Other
Billing Party's Full Address
*
If applicable, write "Same as Above"
Billing Party's City/Town
Billing Party's Postal Code
Billing Party's Home Phone Number
(###)
###
####
Billing Party's Work Phone Number
(###)
###
####
Billing Party's Cell Phone Number
(###)
###
####
Billing Party's Preferred Phone Number
Home
Work
Cell
Billing Party's Marital Status
Billing Party's Relationship to Patient
*
Occupation
Employer
Name(s) of Parent(s) or Step-Parent(s) other than Billing Party - Please Specify
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 #
Growth & Development
Has your child reached their adolescent growth spurt?
Yes
No
Unsure
For girls - Has the menstrual cycle started? If so, when?
Is your child adopted? If so, do they know?
No
Yes, and they know
Yes, and they do not know
Are there any other children in the family? If yes, please give gender and ages.
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.
*
Does your child have a learning disability?
Medical & Dental History
Who is your child's general dentist?
*
Has your child seen their 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)
*
Has your child ever 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
Has your child 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
Is your child taking any medication?
*
No
Yes
Please indicate type, dosage, and reason for any medications being taken.
Please elaborate on any medical or dental concerns for your child.
Does your child have any allergies?
*
No
Yes - please list below
Please list all allergies if applicable.
Is there anything else you'd like to share with us at this time?
We will be asking you to sign this form electronically at your child's consultation appointment.
Thank you for submitting your information! We look forward to meeting you soon!
