Fill Out Form Canadian Child Patient Registration

About Your Child Fields marked with * are required

Todays Date

Patients Name *

Preferred Name

* Male Female

Birthdate *

Address *

City *

Province *

Postal Code *

Childs Home Phone *

School

Grade

Hobbies or interests

Siblings names and ages

Have we seen any other family members? Yes No

If yes who?

How did you hear about our practice?

Reason for orthodontic consultation

Who noticed an orthodontic problem Patient Parent Dentist Other

Mother Information Fields marked with * are required

Mother's First Name

Mother's Last Name

Birthdate

SS#

Mother / Step Mother / Legal Guardian

Email Address

Phone #

Legal Custody Yes No

Home Address

City

Province

Postal Code

Occupation

Employer

How Long

Work Phone #

Father Information Fields marked with * are required

Father's First Name

Father's Last Name

Birthdate

SS#

Father / Step Father / Legal Guardian

Email Address

Phone #

Legal Custody Yes No

Home Address

City

Province

Postal Code

Occupation

Employer

How Long

Work Phone #

Parents marital status Married Single Divorced Widowed Separated Remarried

Responsible Party & Emergency Contact Fields marked with * are required

Responsible party name *

Birthdate *

Relation *

SS#

Legal Custody * Yes No

Email Address

Phone # *

Home Address *

City *

Province *

Postal Code *

Occupation

Employer

How Long

Work Phone #

Person responsible for making appointments

Relation

In case of emergency please contact

Phone #

Dental Insurance Fields marked with * are required

Do you have dental insurance? * Yes No

Does this policy have orthodontic coverage for this minor? * Yes No Don’t Know

Primary insurance: Name of Insurance Carrier

Employer

Carrier Address

City

Province

Postal Code

Phone #

Primary Insured Full Name

Primary Birthdate

Relationship to patient

Member ID#

Group #

Secondary insurance (if applicable): Name of Insurance Carrier

Employer

Carrier Address

City

Province

Postal Code

Phone #

Primary Insured Full Name

Primary Birthdate

Relationship to patient

Member ID#

Group #

Growth & Misc Information Fields marked with * are required

Has puberty begun? Yes No

Has menstruation begun? (Girls) Yes No

Has voice changed? (Boys) Yes No

Mother’s Height

Father’s height

Do you feel growth is complete? Yes No

What are the main concerns about your child’s teeth?

Have parents or siblings had orthodontic treatment? Yes No

Has your child consulted an orthodontist previously? Yes No

Who?

Has there been previous orthodontic treatment? Yes No

Please describe

Dental History Fields marked with * are required

Patients Dentist’s Name

City

Phone #

Last Visit

Did they refer you to our office? Yes No

How often does patient brush?

Floss?

Frequency of dental checkups Twice a year Once a year As needed Never

Patients interest in orthodontic treatment * Eager for treatment Willing if necessary Dreading but agrees Unwilling

Please check if there is a history of: Fields marked with * are required

Clenching/grinding

Lip sucking/biting

Tension headaches

Bleeding gums

Thumb sucking

Tongue thrust

Speech problems

Multiple cavities

Nail biting

Jaw joint pain (TMJ)

Mouth breathing

Poor oral hygiene

Is any part of mouth sensitive to temperature or pressure? * Yes No

Explain

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

Have any primary or permanent teeth been removed? * Yes No

Why?

Has your child had any facial or dental injuries? * Yes No

Explain

Medical History Fields marked with * are required

Patients Physician’s Name

City

Phone #

Last Visit

Please describe your child’s current physical health Good Fair Poor

Is patient currently under physician’s care? * Yes No

Explain

Is patient currently taking any medications or vitamins? * Yes No

List

Please list ANY & ALL known allergies you are aware of (ex: latex, metals, foods, plastics, drugs/medications) *

Is the patient currently, or have previously taken any medications known as Bisphosphonates or bone density medications? (ex: Aclast, Actonel, Actonel+Ca, Aredia Atelvia, Binosta, Bonefos, Boniva, Didronel, Fosamax, Fosamax+D, Reclast, Skelid, or Zometa) * Yes No

When?

Please check if there is a history of: Fields marked with * are required

ADD/ADHD

Aids/HIV Positive

Airway concerns

Anemia

Anxiety/Depression

Asthma

Autism

Blood disorder

Bone disorder

Cancer

Chemical dependency

Chemo/radiation

Circulatory problems

Cough (persistent)

Developmental disorder

Diabetes

Epilepsy

Fainting

Handicap/disability

Headaches (frequent)

Heart problems

Hemophilia

Hepatitis

Lupus

Nervous system problem

Psychiatric Care

Respiratory disease

Rheumatic/scarlet fever

Sleep disordered breathing

Stomach ulcers

Thyroid problems

Tobacco habit

Tonsillitis

Tonsils/adenoids removed

Please use this space to explain any above answers or list any additional health information we should know about *

Has the patient had any surgeries or hospital stays? * Yes No

Explain

Financial and Treatment Authorization Fields marked with * are required

* I affirm that the information I have given is accurate and complete to the best of my knowledge. It is my responsibility to inform this office of any changes in my child’s personal information or health status. I will not hold this office, our doctors or staff responsible for any errors or omissions I have made in the completion of this form.

This office accepts insurance, I assign directly to Dr. Ballard all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.

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

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by ASHA, the CDC and the ADA.

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: 10/27/2026

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