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Blog
For Patients
About Orthodontics
Wearing Braces
Invisalign®
Contact

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Quick Contact Patient Login

Patient Form

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PERSONAL INFORMATION:
Name
First Last
Age
Please enter a number from 0 to 130.
Sex
- Female
- Male
Identifies as:
Date Of Birth
DD slash MM slash YYYY
1- Guardian Name
1- Relation
Phone (1-Guardian)
2- Guardian Name
2- Relation
Phone (2-Guardian)
Address*
Street Address City Province Postal Code
Phone (home)
Phone (cell)
Phone (work)
Email Address
Preferred Office Location*
FAMILY DENTIST
Family Dentist Name
Family Dentist Phone
Whom may we thank for referring you?
In Case Of Emergency Notify
Please fill Name and Phone Number
Person Responsible For Payments
Family Physician
Please fill Name and Phone Number

DENTAL INSURANCE
Do you have Dental Insurance
- YES
- NO
Policy Holder's Name
Policy Holder's Date of Birth
DD slash MM slash YYYY
Name Of Insurance Company
Group/Policy #*
Certificate/ID #*
Coverage Details: Maximum $ Value
Reimbursement rate %
Please enter a number from 1 to 100.
Policy Holder's Name
Policy Holder's Date of Birth
DD slash MM slash YYYY
Name Of Insurance Company
Group/Policy/Cert.
Certificate
I.D.
Coverage Details: Maximum $ Value
Reimbursement rate %
Please enter a number from 1 to 100.

PATIENTS MEDICAL HISTORY
1) Have you taken any kind of drugs or medicine in the past 2 years?*
- YES
- NO
2) Are you allergic to latex, penicillin or any other drugs or medications?*
- YES
- NO
3) Do you ever have chest pains?*
- YES
- NO
4) Have you ever experienced unexplained shortness of breath?*
- YES
- NO
5) Have you ever experienced excessive bleeding that required special treatment?*
- YES
- NO
6) Do you have a history of fainting, dizziness or vertigo?*
- YES
- NO
7) Do you have any nervous disorders?*
- YES
- NO
8) Have you had any of the following?
- Heart Trouble
- Kidney Trouble
- Arthritis
- Hay Fever
- Asthma
- Stroke
- Epilepsy
- Congenital Heart Lesions
- Heart Murmur
- Diabetes
- Severe Allergies
- High Blood Pressure
- Hepatitis
- Rheumatic Fever
- Sinus Trouble
- Bleeding Disorder
- HIV
- Tuberculosis
- Digestive Disorder
- Chest pain/Shortness of breath
Elaborate on any “Yes” responses to the question above.
9) Have you ever had any other serious illnesses or contagious diseases?*
- YES
- NO
10) (Woman) Are you pregnant now?*
- YES
- NO
11) Have you ever been a patient in hospital during the past 2 years?*
- YES
- NO
12) Have you been diagnosed with A.D.H.D.?*
- YES
- NO
Comments (e.g. elaborate on any “Yes” responses)
I confirm the above information is accurate and complete*
- YES
- NO

new westminster orthodontist office

New Westminster

612 Belmont St
New Westminster, BC
604-522-9871

coquitlam orthodontist office

Coquitlam

Suite 640
2755 Lougheed Highway
Port Coquitlam, BC
604-552-3899

south surrey orthodontist office

Grandview Corners

Suite 225
2411 160th Street
Surrey, BC
604-385-0805

surrey orthodontist office

Clayton Heights

Suite 107
6758 188th Street
Surrey, BC
778-574-8484

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