Medical History Form

Office Location

Select an office to submit your information

Location(required)

Queenston Office

Upper James Office

Patient Information

Title

Sex

Female

Male

Legal Name(required)

Last Name(required)

Preferred Name

Birthdate(required)

Month Day Year

Age(required)

Best phone to reach you(required)

Home Phone(required)

Cell Phone

Best number for appointment confirmation by text.

Work Phone

Parent Full Name(required)

First and last name of your parent or guardian

Parent Phone(required)

Email(required)

Home Address(required)

City(required)

Province(required)

Postal Code(required)

Name of School

Who may we thank for referring you to our office?(required)

Siblings?

Yes

Sibling 1

Full Name

First and Last Name

Birthdate

Month Day Year

Sex

Female

Male

Additional siblings?

Yes

Sibling 2

Full Name

First and Last Name

Birthdate

Month Day Year

Sex

Female

Male

Additional siblings?

Yes

Sibling 3

Full Name

First and Last Name

Date

Month Day Year

Sex

Female

Male

Responsible Party Information

If you have orthodontic coverage, please complete the insurance information

Full Legal Name

First and Last Name

Title

Relationship to patient

Marital Status

Email address

Cell Phone

Work Phone

Home Address (if different)

City

Province

Postal Code

Responsible Party Information

If you have orthodontic coverage, please complete the insurance information

Full Legal Name

First and Last Name

Title

Relationship to patient

Marital Status

Email address

Cell Phone

Work Phone

Home Address (if different)

City

Province

Postal Code

Insurance Information

Member’s Full Name On The Policy

First and Last Name

Birthdate

Month Day Year

Name of Insurance Company

Policy / Group / ID #

Certificate #

Name of Group or Policy Holder or Employer

Name of Employer:

Employer Address:

Telephone:

City:

Postal Code:

Coordination of benefit?

Yes

Dual Coverage Insurance

Members Name on the policy

Birthdate

Month Day Year

Name of Insurance Company

Policy / Group / ID #

Certificate #

Name of Group or Policy holder or Employer

Legal Name Of Insured :

Name of Employer:

Employer Address:

Telephone:

City:

Postal code:

Medical and Dental History of the Patient

Pregnant?(required)

Yes

Smoker?(required)

Yes

Patient has history of medical conditions?(required)

Yes

Check all that apply

Arthritis

Diabetes

Epilepsy

Anemia

HIV

Asthma

Bleeding disorders

High Blood Pressure

Hepatitis A

Hepatitis B

Hepatitis C

Other

Currently under any medical treatment?(required)

Yes

Current Medical Treatment(s)

Currently under any medications?(required)

Yes

Medications

Do you need to be premedicated?(required)

Yes

Do you carry an EpiPen?(required)

Yes

Allergies?(required)

Yes

List any allergies

(Sulfa, Penicillin, Novocain, Metal, Latex etc.)

Is there a heart condition?(required)

Yes

Please describe heart condition

Is there a tendency to faint or become dizzy?(required)

Yes

Please describe tendency

Is there any pain, clicking, and/or popping noises in the jaw?(required)

Yes

Are you aware of either clenching or grinding of teeth?(required)

Yes

Is there frequent snoring and/or sleep apnea?(required)

Yes

Any habits?(required)

Yes

HabitsNail Biting, Finger or thumb sucking, Lip or cheek biting, Tongue Thrusting

Nail Biting

Finger or thumb sucking

Lip or cheek biting

Tongue Thrusting

Mouth Breathing

Are there any speech problems?(required)

Yes

Describe speech problem(s)

Have there been any injuries to the teeth?(required)

Yes

Describe injuries

Patient’s Current Dentist’s Name

Dentist’s Phone

Patient’s Current Family Doctor’s Name

Doctor’s Phone

I confirm that Red Hill Orthodontics may send me emails regarding my appointment notifications, insurance/tax receipts, instructions,and other practice information. My email will not be shared with any 3rd party at any time. (Note that we use several different software programs to send out emails, so if you opt in and later decide to opt out, please call us to inform us personally).(required)

I Agree

I consent to the use of my (child’s) image by Red Hill Orthodontics, which may be used on Social Media platforms managed by Red Hill Orthodontics and future marketing/communications collateral. I agree that I shall have no claim against Red Hill Orthodontics or against anyone accessing this communications/marketing material, whether online, in print or by any other means. I confirm that I have parental consent or am over 19 years of age, and that I have not given anyone the exclusive right to use my image.(required)

Yes

I hereby consent to have my orthodontic records and information discussed and/or communicated electronically with my dental, medical and insurance parties (required)

Agree

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