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: 1/22/2021

Howdy folks, with this problematic virus running around, we thought it would be helpful to let you know a little about what we are doing here to keep you safely out of it's reach. Please know that we have always been on the front lines of preventing the spread of diseases and have always gone to great lengths to follow appropriate guidelines. From treatment and waiting room disinfection to the strict use of personal protective equipment (PPE), the safety of our patients and staff continues to be of utmost importance.

And, when it comes to preventing the spread of this particular Coronavirus, rest assured Dr. Ballard has always been strict on universal precautions. These precautions include the use of masks, glasses, gloves, gowns and sterile instruments as well as clean and disinfected environmental surfaces. Additionally, frequently touched surfaces such as door handles, chairs, desks and bathrooms are cleaned and disinfected at frequent intervals during the day.

While your check-in process may involve a few extra steps this will help ensure the safety of you and the staff. For instance our process now includes screening and triage questions when we confirm your appointment as well as when you arrive. Waiting in your vehicle versus the waiting room can be helpful. If you would like to wait in your vehicle, simply text us at (208) 946-5650 when you arrive and we will text you back when it is time to bring you back into our treatment area. Checking your temperature or asking that you follow social distancing and infection control etiquette is a regular occurrence. And, we would ask, to the best of your ability you refrain from bringing companions to appointments, unless necessary. For our younger patients, having one parent accompany them is ideal. For our teenage patients, rest assured if there is anything that needs to be addressed with a parent, we will contact you directly and provide an update. Otherwise know that treatment is progressing well.

You will note our waiting room chair arrangement allows for 6 feet between seated patients, all of the video games, magazines, toothbrushes, pens, toys etc have been removed (sorry but it will make the area more hygienic.) You are all requested to brush your teeth at home prior to your orthodontic appointment. We have hand sanitizer in multiple locations within the office. Blue tape at the receptions desks help encourage separation as well. There will typically be less patients in the office at one time to promote social distancing. You will see the orthodontic assistance in disposable gowns and wearing masks and face-shields. Of course hands are washed over and over and over and then washed again. Staff, including Dr. Ballard will not be at work if they have symptoms of or are diagnosed with COVID-19 and patient appointments are rescheduled if diagnosis and/or symptoms of COVID 19 are present for them. If you have any questions or concerns, please don’t hesitate to ask us.

Rest assured Dr. Ballard will be following recommended precautions to treat all orthodontic patients safely. Having said that, despite our best attempt at avoiding, eliminating, reducing and minimizing the risk of any communicable disease, there is still a chance an individual may pick one up at our office. Likely due to scenarios that neither we or anyone else have considered, or may even be aware of. We simply don’t know all things about this particular Coronavirus. So, please understand while the risk we believe is minimal and significantly mitigated in our office it is not completely eliminated and we respect your right to postpone visits if you are concerned. If you elect to postpone visiting our office, please communicate this to us. Generally speaking, unmonitored and unsupervised orthodontic treatment poses increased risk for unwanted side affects including root shortening, gum tissue recession, and a variety of other undesirable side affects. So, again if you determine to avoid visiting our office in the short term, please let us know so we can make a plan for how and when to move forward with orthodontic treatment.

For most of us, this particular virus will be a nuisance and inconvenient but manageable. For a few, they will have a tougher time. Fortunately our patient population is, for the most part, a low risk group relative to negative outcomes. In the end we are optimistic that with these adjustments, a positive attitude and a healthy lifestyle . . . including straight teeth, there will be many great (and COVID-19 free) days ahead!!

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