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Appointment Request
, Child Form, Orthodontist Toronto Beach | Braces Toronto Beach | Invisalign Toronto Beach

“Take a minute to review, print and fill out our patient information form

before your first visit to save you time on arrival!”

    PATIENT INFORMATION
    Patient's Name:
    Date:
    Date of Birth:
    Age:
    Sex:
    School:
    Grade:
    Home Address:
    City:
    Postal Code:
    Tel:
    Number of Children in Family:
    Age & Names of Other Children:
    Patient’s Dentist:
    Patient’s Dentist Tel:
    Family Physician:
    Physician Tel:
    Who may we thank for referring you?
    Parent/Guardian’s E-mail:
    Responsible Party 1:
    Relation:
    Home Tel:
    Day Time Tel:
    Tel Type:
    Responsible Party 2:
    Relation:
    Home Tel:
    Day Time Tel:
    Tel Type:
    Person Responsible for Account:
    Do you have an insurance plan that covers orthodontic treatment?
    YesNoUnsure
    MEDICAL HISTORY
    HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
    Rheumatic Fever
    YesNo
    Tuberculosis
    YesNo
    Diabetes
    YesNo
    Heart Murmur
    YesNo
    H.I.V./A.I.D.S.
    YesNo
    Kidney Disorder
    YesNo
    Mitral Valve Prolapse
    YesNo
    Hepatitis A, B, or C
    YesNo
    Liver Disease
    YesNo
    Heart Disease
    YesNo
    Sexually Transmitted Diseases
    YesNo
    Asthma
    YesNo
    Artificial Heart Valve
    YesNo
    Blood Disease
    YesNo
    Arthritis
    YesNo
    Artificial Joints
    YesNo
    Prolonged Bleeding
    YesNo
    Other
    If you responded YES to any of the above, please give pertinent information:
    Is the child in good health?
    Does the child have any history of major illness and/or operations?
    List any drugs or medication now being taken: Please give reasons:
    List any allergies or drug sensitivities
    Does the child have a tendency to colds?
    Sore Throats?
    Ear Infections?
    Have tonsils or adenoids been removed?
    at what age?
    Has the patient reached puberty? Girls-Has menstruation started?
    YesNo
    Boys-Has voice changed yet?
    YesNo
    DENTAL HISTORY
    Has the child ever been treated for a jaw joint problem, including surgery?
    YesNo
    Please describe:
    Have there been any injuries to the face, mouth or teeth?
    YesNo
    Please describe:
    Has the child ever sucked his/her thumb or finger?
    YesNo
    Until What age:
    Does the child have any speech problems?
    YesNo
    Does the child have frequent canker or cold sores?
    YesNo
    Is the child a mouth breather? While Asleep:
    YesNo
    While Awake:
    YesNo
    Have you been informed of any missing or extra permanent teeth ?
    YesNo
    Has the child ever had a previous orthodontic examination?
    YesNo
    Is the child especially apprehensive toward dental visits?
    YesNo
    Does the child want orthodontic treatment?
    YesNo
    Has any other family member had braces or orthodontic treatments?
    YesNo
    If yes, name of family member if treated in our office:
    When did the child last see the family dentist?
    List any sports, hobbies or musical instruments
    Reason for orthodontic consultation:

    RELEASE OF INFORMATION:I hereby give Dr. J. Daskalogiannakis and/or members of his staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.

    Signature of Parent or Guardian:
    Date

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