New Patient Form

Postal Code *

Check any conditions that apply

Heart murmur/heart disease/heart attack

Stroke

Kidney/liver disease

Arthritis

Asthma/COPD

Epilepsy

Seizures

Cancer

Radiation Treatment

Mental Illness

Autism

Special Needs

Diabetes

Severe Allergies

High Blood Pressure

Hepatitis

Rheumatic Fever

Sinus Trouble

Bleeding Disorder

HIV

Tuberculosis

Fainting

Hearing Impairment

Covid-19

Other not listed

Insurance Company Name (Dental Insurance Plan #2)

9. (Women) Are you pregnant now? *

Yes

No

Emergency Contact #

Policy Holder Date of Birth (Dental Insurance Plan #1)

Policy Holder Name (Dental Insurance Plan #2)

Last Name *

Parent's Adress (if patient is minor)

Sex *

Male

Female

Other

Parent's Postal Code (if patient is minor)

Parent's First Name (if patient is minor)

Final Confirmation *

I confirm all information provided above is accurate and complete to the best of my knowledge.

14. Fever (defined as above 38°C)? *

Yes

No

17. Muscle aches? *

Yes

No

Patient Name (Consent for Care): *

Parent's Last Name (if patient is minor)

Email *

I authorize examination/treatment from Pitt Meadows Orthodontics including the use of radiographs (X-rays), the administration of anesthetics, as may be recommended for my treatment. I also authorize the taking of images (including for example photographs, radiographs and films) and the creation of any other records (electronic and/or hardcopy) for the purpose of treatment, teaching, presentations, publications, research, or marketing. I understand that the records will be anonymous in order to protect my identity. Further, if applicable, I authorize Pitt Meadows Orthodontics to release the required records to my dental insurance provider(s) in order to submit a pre-determination for treatment, and to receive payment from the insurance provider for services rendered. *

I confirm that I am the legal guardian of the person listed above.

16. Chills? *

Yes

No

Date of Last Dentist Visit

Physician's Phone #

3. Are you taking any medication or drugs (if yes, please list below)? *

Yes

No

Date of Birth

For minor patient, name of parent/legal guardian:

Supplemental Informed Consent for Orthodontic Treatment in the Era of Covid-19. Thank you for your trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 also known as “Coronavirus”, at any time or in any place. Be assured that we have always followed provincial regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our clinic, just as you might be at you’re your gym, grocery store or favorite restaurant. “Physical Distancing” has reduced the transmission of the Coronavirus. Although we have taken measures to provide distancing within our practice, due to the nature of the procedures we provide, it is not possible to maintain physical distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times. *

Although exposure is unlikely, I accept the risk and consent to treatment

11. Dry Cough? *

Yes

No

Cellphone *

I.D./Cert # (Dental Insurance Plan #1)

Other condition that is not listed above:

Main concerns for your upcoming appointment

First Name *

Mother's Name (if patient is a minor)

Address *

Insurance Company Name (Dental Insurance Plan #1)

12. Sore throat or painful swallowing? *

Yes

No

Father's Phone #

Policy Holder Date of Birth (Dental Insurance Plan #2)

2. Have you been under the care of a physician during the past 2 years for a medical condition? *

Yes

No

Policy Holder Name (Dental Insurance Plan #1)

Group/Policy/Plan # (Dental Insurance Plan #2)

5. Have you been diagnosed with ADHD or ADD? *

Yes

No

13. Shortness of breath? *

Yes

No

Home Phone

19. Fatigue? *

Yes

No

6. Have you ever experienced unexplained shortness of breath or chest pains? *

Yes

No

1. Have you ever been a patient in hospital during the past 2 years? *

Yes

No

7. Have you ever experienced excessive bleeding that required special treatment? *

Yes

No

10. Previous Orthodontic Consult? *

Yes

No

Parent's Email (if patient is minor)

Parent's City (if patient is minor)

I.D./Cert # (Dental Insurance Plan #2)

Father's Name (if patient is a minor)

8. Have you ever had any of the following conditions (if yes, please list below)? *

Yes

No

List of Allergies

City *

List of Medication

4. Are you allergic to latex, penicillin or any other drugs or medications (if yes, please list below)? *

Yes

No

Mother's Phone #

20. Have you had close contact or been in isolation with a suspected Covid-19 case in the past 14 days? *

Yes

No

18. Headache? *

Yes

No

Family Physician

Family Dentist

Group/Policy/Plan # (Dental Insurance Plan #1)

15. Loss of appetite? *

Yes

No

Emergency Contact Name

Additional Email for Appointment Reminders

Physician/Dentist Information

Dental Insurance Plan #2

For minor patient

Consent for Care

COVID-19 Questionnaire

New Patient Form

Dental Insurance Plan #1

Medical History