Health History Form

Patient Information

Name:

Last Name

First Name

Middle Initial

Age:

Preferred Name:

Gender:MaleFemale

Date of Birth:

Address:

Street

Apt/Suite

City

Province

Postal Code

Email address (responsible party):

General Dentist’s Name/Practice:

Last Visit to Dentist:

How did you hear about our office?DentistFriends/FamilyGoogleInstagramFacebookOther

Please complete this section if the patient is under 18:

Mother’s Information:

Name

Cell

Work

Father’s Information:

Name

Cell

Work

Guardian’s Information:

Name

Cell

Work

Additional Information

Reason(s) for seeking orthodontic consultation?

Have you consulted an orthodontist before or had previous orthodontic treatment?

Is there anything special about your child that you would like to share with us?

Insurance Information

Do you have insurance?YesNo

Do you have more that one insurance carrier? YesNo

Do you know what your orthodontic coverage is?YesNo

Who is responsible for patient’s account?MotherFatherGuardianOther

If other, specify

Name of Primary Insurance Company:

Employer:

Group/Policy #

Name of Insured:

Date of Birth:

ID/Cert. #

Name of Second Insurance Company:

Employer:

Group/Policy #

Name of Insured:

Date of Birth:

ID/Cert. #

Dental History

Yes

If yes, please explain:

Has the patient suffered any trauma to teeth/head/face?

Yes

If yes, please explain:

Is there a history of thumb/finger sucking or mouth habits?

Yes

If yes, please explain:

Has the patient ever had a bad dental experience?

Yes

If yes, please explain:

Does the patient have any discomfort with their current bite?

Yes

If yes, please explain:

Does the patient have any speech problems?

Yes

If yes, please explain:

History of jaw joint problems/pain (TMJ)?

Yes

If yes, please explain:

Medical History

Yes

If yes, please explain:

Is there any risk of being pregnant?

Yes

If yes, please explain:

Does your child have any health problems?

Yes

If yes, please explain:

Is your child taking any medications?

Yes

If yes, please explain:

Does your child have any allergies?

Yes

If yes, please explain:

Does your child experience excess bleeding?

Yes

If yes, please explain:

Has your child ever taken bisphosphonates (bone problems)?

Yes

If yes, please explain:

Any other condition or disease that we should know about?

Yes

If yes, please explain:

Authorization

To the best of my knowledge, the above is complete and correct. I understand that it is my responsibility to inform my doctor at Willow Orthodontics of any changes in my child’s health while he/she is under orthodontic treatment.

I am the parent/guardian of .I do hereby request and authorize the staff/doctor to perform necessary dental services for the child named above, including but not limited to x-rays, which are deemed advisable by the doctor, whether or not I am present when the treatment is rendered.

Date:

Signature of Parent/Legal Guardian:

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

Your information at Willow Orthodontics 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 or Responsible Party Consent

I,, consent to the collection, use and disclosure of my child’s 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 Willow Orthodontics. This consent to release information will remain in effect until such time notification is received.

Patient Name (PLEASE PRINT):

Witness:

Signature of Parent/Legal Guardian:

Date: