Fill Out Form Canadian Child Patient Registration

New Patient Registration Fields marked with * are required

First Name & Middle Initial *

Last Name *

Preferred Name

Gender * Male Female

Date Of Birth *

SSN

Address *

Address (optional)

How Long

Municipality *

Province *

PostalCode *

Primary Phone *

Work Phone

Emergency Phone

I (we) Prefer Communication By Phone Text Email

Student Status

General Dentist

General Dentist's Phone Number

Last Visit Date

Mother's Information Fields marked with * are required

First Name & Middle Initial

Last Name

Preferred Name

Date of Birth

Driver's Licence Number

SSN

Marital Status

Address

Address (optional)

How Long

Municipality

Province

PostalCode

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

How Long

Employment Status

Father's Information Fields marked with * are required

First Name & Middle Initial

Preferred Name

Date of Birth

Driver's Licence Number

SSN

Marital Status

Address

Address (optional)

How Long

Municipality

Province

PostalCode

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

How Long

Employment Status

Responsible Party (if someone other than mother or father) Fields marked with * are required

Relation To Patient

First Name

Last Name

Preferred Name

Gender Male Female

Date Of Birth

Driver's License Number

SSN

Marital Status

Address

Address (optional)

Municipality

Province

PostalCode

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Insurance Information Fields marked with * are required

If you would please complete the following insurance information, we will be happy to design payment options and provide information regarding how your insurance should reimburse you.

Dental Coverage * Yes No

Orthodontic Coverage * Yes No

Insurance Company Name

Your Cert. No. or S.I.N. or I.D. No.

PLAN CONTACT NO. GROUP NUMBER, OR POLICY NO.

Phone Number

Subscriber's First Name

Subscriber's Last Name

Subscriber's Date of Birth

Relationship to Patient

Gender Male Female

Insurance Company's Address

Address (optional)

Municipality

Province

PostalCode

Employer

Occupation

Employment Status

Lifetime Maximum

Payment Percentage

Deductible

Adult Coverage Yes No

Secondary Insurance Information Fields marked with * are required

If you would please complete the following insurance information, we will be happy to design payment options and provide information regarding how your insurance should reimburse you.

Dental Coverage Yes No

Orthodontic Coverage Yes No

Insurance Company Name

Your Cert. No. or S.I.N. or I.D. No.

Plan Contact No. Group number, or Policy No.

Phone Number

Subscriber's First Name

Subscriber's Last Name

Subscriber's Date of Birth

Relationship to Patient

Gender Male Female

Insurance Company's Address

Address (optional)

Municipality

Province

PostalCode

Employer

Occupation

Employment Status

Lifetime Maximum

Payment Percentage

Deductible

Adult Coverage Yes No

Emergency Contact Fields marked with * are required

His / Her Name

Relationship

Primary Phone

Work Phone

Health History Fields marked with * are required

What are the main concerns that you would like orthodontics to accomplish?

Has your child ever been evaluated or had orthodontic treatment before? Yes No

Have there been any injuries to the face, mouth, teeth, or chin? Yes No

List any musical instruments played

Have adenoids or tonsils been removed? Yes No

Has your child been informed of any missing or extra permanent teeth? Yes No

Has your child ever had any pain / tenderness in his / her jaw joint (TMJ/TMD)? Yes No

Does your child brush his / her teeth daily? Yes No

Child’s Physician

Is your child currently under the care of a physician? Yes No

Has puberty begun? Yes No

Has menstruation begun? (Girls) Yes No

Please describe your child's current physical health

Does / did your child have any of the following habits? Fields marked with * are required

Clenching / Grinding Yes No

Lip Sucking / Biting Yes No

Mouth Breather Yes No

Nail Biting Yes No

Nursing Bottle Yes No

Speech Problems Yes No

Thumb / Finger Sucking Yes No

Tongue Thrust Yes No

Is your child allergic to any of the following? Fields marked with * are required

Asprin * Yes No

Penicillin * Yes No

Codeine * Yes No

Are you allergic to Acrylic? * Yes No

Are you allergic to Metal? * Yes No

Are you allergic to Latex? * Yes No

Are you allergic to Sulfa Drugs? * Yes No

Are you allergic to Local Anesthetics? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Please list any other drug/materials that your child is allergic to:

Does / did your child have any of the following? Fields marked with * are required

ADHD

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Has your child ever had any serious illness not listed? * Yes No

If Yes:

Comments

How Did You Hear About Our Office? Fields marked with * are required

Dentist

Internet

Location / Sign

Family / Friend

Newspaper

Phone Book

Other

Terms And Conditions Fields marked with * are required

Terms * I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Release Authorization Fields marked with * are required

I authorize Ballard Orthodontics to release my medical and/or billing information to the following individuals:

HIPAA and Privacy Practices Consent Fields marked with * are required

HIPAA Consent * I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews.
I give this practice consent to leave messages with household members and answering machines when necessary.
I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent.
I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice.
I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s).
I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Signature Fields marked with * are required

Date: 7/3/2022

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