Office Location Select an office to submit your information Location(required) Queenston Office Upper James Office Patient Information Title Mr. Mrs. Ms. Miss. Dr. Sex Female Male Legal Name(required) Last Name(required) Preferred Name Birthdate(required) Month Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 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) Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon 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 Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 Sex Female Male Additional siblings? Yes Sibling 2 Full Name First and Last Name Birthdate Month Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 Sex Female Male Additional siblings? Yes Sibling 3 Full Name First and Last Name Date Month Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 Sex Female Male Responsible Party Information (Father) If you have orthodontic coverage, please complete the insurance information Full Legal Name First and Last Name Title Mr. Mrs. Ms. Miss. Dr. Relationship to patient Marital Status Single Married Divorced Widowed Email address Cell Phone Work Phone Home Address (if different) City Province Select a Province Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code Responsible Party Information (Mother) If you have orthodontic coverage, please complete the insurance information Full Legal Name First and Last Name Title Mr. Mrs. Ms. Miss. Dr. Relationship to patient Marital Status Single Married Divorced Widowed Email address Cell Phone Work Phone Home Address (if different) City Province Select a Province Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code Insurance Information Member’s Full Name on the policy First and Last Name Birthdate Month Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Name of Insurance Company Policy / Group / ID # Certificate # Name of Group or Policy holder or Employer Coordination of benefit? Yes No Dual Coverage Insurance Members Name on the policy Birthdate Month Month January February March April May June July August September October November December Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 Name of Insurance Company Policy / Group / ID # Certificate # Name of Group or Policy holder or Employer Medical and Dental History of the Patient Pregnant?(required) Yes No Smoker?(required) Yes No Patient has history of medical conditions?(required) Yes No Check all that apply Arthritis Diabetes Epilepsy Anemia HIV Asthma Bleeding disorders High Blood Pressure Hepatitis A Hepatitis B Hepatitis C Other Other Currently under any medical treatment?(required) Yes No Current Medical Treatment(s) Currently under any medications?(required) Yes No Medications Do you need to be premedicated?(required) Yes No Do you carry an EpiPen?(required) Yes No Allergies?(required) Yes No List any allergies (Sulfa, Penicillin, Novocain, Metal, Latex etc.) Is there a heart condition?(required) Yes No Please describe heart condition Is there a tendency to faint or become dizzy?(required) Yes No Please describe tendency Is there any pain, clicking, and/or popping noises in the jaw?(required) Yes No Are you aware of either clenching or grinding of teeth?(required) Yes No Is there frequent snoring and/or sleep apnea?(required) Yes No Any habits?(required) Yes No 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 No Describe speech problem(s) Have there been any injuries to the teeth?(required) Yes No 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 No I hereby consent to have my orthodontic records and information discussed with my dental, medical and insurance parties.(required) Agree Submit Please wait…
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[contact-form-7 404 "Not Found"]
