Ortho GroupN Adult Patient form fillable

Adult Form

OrthoGroup North

Dr. Robert Kinniburgh

Panorama Crossing 42 Panatella Blvd NW Calgary AB T3K 6K7

E: north@orthogroup.ca
P: 403.226.1991
F: 403.717.0491

OrthoGroup NORTHWEST

Dr. C. Todd Lee-Knight

Country Hills Village Shopping Centre Suite 246, 5149 Country Hills Blvd. NW Calgary AB T3A 5K8

E: northwest@orthogroup.ca
P: 403.208.8080
F: 403.208.8088

Your oral health and safety are our priorities. The following information enables us to provide you with the best orthodontic care, safely and effectively. Please complete the entire form. During your visit, you will be asked questions regarding your questionnaire responses. All information is confidential and treated in accordance with applicable provincial and federal privacy legislation.

Patient Information

Name: Last

First

Middle Initial

Mr. Mrs. Ms. Dr.

Preferred first name:

Gender:

Male Female

Date of Birth (MM/DD/YYYY):

Address: Street

Apt/Suite

City

Province

Postal Code

Phone: Home

Cell

Work

Phone: Home

Cell

Work

Email address:

Employer:

Occupation:

General Dentist’s Name:

Physician’s Name:

Emergency Contact: Name

Phone

Relationship to patient

Whom may we thank for referring this patient to our office?

Insurance Information:

Name of Primary (Insurance Company:)

Employer:

Group/Policy #

Name of Insured:

Date of Birth (MM/DD/YYYY):

ID/Cert. #

Name of Second (Insurance Company:)

Employer:

Group/Policy #

Name of Insured:

Date of Birth (MM/DD/YYYY):

ID/Cert. #

Dental History

No Yes

If yes, please explain

Have you suffered any trauma to teeth/head/face?

Have you had history of any mouth habits?

Have you consulted an orthodontist previously?

Have you had any previous orthodontic treatment?

Have you had a bad dental experience?

Do you have any discomfort with your current bite?

Do you have any speech problems?

Have you had any of the following?

No Yes

History of jaw joint problems (TMJ)

Ringing in the ears

Clenching/grinding teeth

Jaw joint soreness/pain

Muscle soreness of head/neck/jaw joint

Jaw joint clicking/popping

Difficulty opening mouth

Jaw joint locking (open/closed)

Medical History

No Yes

Are you in good health?

If no, explain:

Are you currently taking any medications?

List:

Do you have any allergies (food/medication/latex/penicillin/metal etc.)?

List:

Do you bruise easily or bleed profusely?

If yes, explain:

Have you ever been hospitalized?

If yes, explain:

Have you ever taken bisphosphonates?

If yes, when/how much/for what?

Female: Are you pregnant?

If yes, how many weeks?

Have you had any of the following?

No Yes

AIDS/HIV+

Epilepsy/seizures

Kidney problems

Anemia

Emotional disturbance

Mitral valve prolapse

Angina

Eye disease

Mouth breathing

Arthritis

Fainting

Nervous disorder/anxiety

Artificial heart valves

Frequent colds/flu

Pneumonia

Artificial joints

Frequent cold sores

Rheumatic fever

Asthma

Frequent cough, skin rash, diarrhea

Sinus trouble

Bone/Blood disorders

Growth disorder

Stomach problems

Blood pressure (high/low)

Gland problems

Stroke

Cancer/tumor

Heart murmur/Heart surgery

Thyroid disease

Congenital heart defects

Heart disease

Tonsilitis

Diabetes

Hepatitis/Liver problems

Tonsil removed | Age:

Depression

Herpes

Tuberculosis

Endocrine problems

Hypoglycemia

Ulcers

Additional Information

What are your reason(s) for seeking orthodontic consultation?

Authorization

To the best of my knowledge, the above is complete and correct. I understand that it is my responsibility to inform my doctor if there are any changes in my health.

Date:

Signature:

OrthoGroup North

Dr. Robert Kinniburgh

Panorama Crossing 42 Panatella Blvd NW Calgary AB T3K 6K7

E: north@orthogroup.ca
P: 403.226.1991
F: 403.717.0491

OrthoGroup NORTHWEST

Dr. C. Todd Lee-Knight

Country Hills Village Shopping Centre Suite 246, 5149 Country Hills Blvd. NW Calgary AB T3A 5K8

E: northwest@orthogroup.ca
P: 403.208.8080
F: 403.208.8088

Patient Consent Form – Collection, Use and Disclosure of Personal Information

Your information at OrthoGroup is protected under provincial and federal legislation. We will use your health information only to support the health services we provide such as; providing your treatment and care, verifying your eligibility for health services, to conduct investigations or reviews of the practice, support health provider education, or for internal management purposes. We will not disclose your health information to non-health care agencies without your consent, except in special family or emergency circumstances. You will be asked for your consent before we give your information to anyone other than another health agency involved in your care. For more information about our privacy and information security policies, you may speak to our Privacy Officer in person or by calling our office.

Patient Consent

I, consent to the collection, use and disclosure of my personal, dental, and health information for the purpose of providing treatment and care. I acknowledge that I have been made aware of the reasons for the disclosure of the above information, and the risks and benefits associated with consenting or not consenting to its release.
I understand that I may revoke my consent at any time, by providing a signed, written statement to OrthoGroup. This consent to release information will remain in effect until such time notification is received.

Patient Name (PLEASE PRINT):

Witness:

Patient Signature:

Date: