New Patient Form

Once you've booked your first appointment at Shuswap Orthodontics, you'll need to fill out our new patient form to get started. You can do this using one of the options below.

Option 1

Complete Online

Complete and submit the online.

Online Form

Option 2

Print & Complete

Bring the completed form with you your first appointment.

Downloadable Form

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our clinic.

Today's Date *

How did you hear about us? (Select all that apply) *

Facebook

Instagram

Our Website

Search Engine (e.g., Google)

Friend

Event

Dentist

Other (Please specify below)

If you other selected, please specify:

Patient Information

Patient Name (First & Last) *

Prefers to be called

Gender

Birthdate *

School (if applicable)

Grade (if applicable)

Phone (1st) *

Phone (1st) - Select One *

Home

Cell Phone

Work

Phone (2nd)

Phone (2nd) - Select One

Home

Cell Phone

Work

Phone (3rd)

Phone (3rd) - Select One

Home

Cell Phone

Work

Email Address *

Mailing Address (street address, city, postal code) *

Dentist

Physician

Other children in family - Include name(s) and age(s)

Parental Information (Child Patients)

If you are completing this form for your child, please complete the fields below.

Name (First & Last)

Select One

Mother

Father

Other

If other, please specify:

Birthdate

Mailing Address (if different - street address, city, postal code)

Phone

Phone - Select One

Home

Cell phone

Work

Employer

Emergency Contact (Adult Patients)

If you are an adult patient, please let us know who should we contact in the case of an emergency.

Name (First & Last)

Select One

Spouse

Parent

Friend

Other

If other, please specify

Birthdate

Mailing Address (if different - street address, city, postal code)

Phone

Phone - Select one

Home

Cell phone

Work

Employer

Medical History

Does the patient smoke? *

Yes

Does the patient have any history of major illness? *

Yes

If yes, please explain:

Is the patient presently under the care of a physician for a major illness? *

Yes

If yes, please explain:

Is the patient currently taking any medications? *

Yes

If yes, please list:

Has the patient been advised to take antibiotics or other medications before dental visits? *

Yes

If yes, please list

Does the patient have allergies to any drugs? *

Yes

If yes, please list:

Does the patient have any other allergies? (E.g., seasonal, food, etc.) *

Yes

If yes, please list:

Has the patient had his/her tonsils removed? *

Yes

If yes, at what age?

Has the patient had his/her adenoids removed? *

Yes

If yes, at what age?

If tonsils and/or adenoids have not been removed, does the patient have regular problems with them? *

Yes

Not applicable

If yes, please explain:

Is the patient prone to colds, sore throats, and/or ear infections? *

Yes

If yes, which?

Does the patient have any physical or mental considerations? (E.g., ADHD, ASD, anxiety, etc.) *

Yes

If yes, please explain:

Does the patient require any extra help during appointments, or with instructions? *

Yes

If yes, pease explain:

Female patients: Are you pregnant or trying to become pregnant? *

Yes

Not applicable

Child patients: Has the patient reached puberty? *

Yes

Not applicable

Is the patient up to date with their vaccinations? *

Yes

If no, please explain:

Please select any of the following that the patient has had problems with: *

Alzheimer’s Disease

Bleeding

Epilepsy/Seizures

Heart Trouble/Disease

Liver Disease

Anaphylaxis

Bone Disorders

Fainting/Dizziness

Heart Valves

Nervous Disorder(s)

Anemia

Cleft Lip/Palate

Hearing

Hemophilia

Pneumonia

Asthma

Diabetes

Heart Murmur

Kidney Disease

Rheumatic Fever

Other (Please specify below)

None

If you other selected, please specify:

Please select any of the following that the patient has or has been exposed to:

Hepatitis

HIV/AIDS

Tuberculosis

STI’s

Please describe any other medical problems not yet covered:

What are the patient’s/parent’s concerns regarding the appearance of the patient’s teeth?

If yes, please explain:

Does the family have a history of an underbite? I.e., the lower teeth extend outward further than the upper teeth. *

Yes

Unsure

If yes, what is the relationship to the patient?

Have there been any injuries to the face, teeth or jaw joints? *

Yes

If yes, please explain:

Does the patient have speech problems? *

Yes

If yes, has the patient had speech therapy? Please explainL

Has the patient ever sucked his/her thumb or fingers? *

Yes

If yes, until what age?

Does the patient snore while sleeping? *

Yes

Does the patient breathe through the mouth, rather than the nose? *

Yes

Usually

Sometimes

Are there any diagnosed or suspected airway/breathing problems, including sleep apnea?

Yes

If yes, please explain:

Has the patient been informed of any missing permanent teeth? *

Yes

If yes, how many, and which teeth?

Has the patient had an orthodontic consultation previously? *

Yes

If yes, when, where and for what type of orthodontic treatment?

Has either parent previously had orthodontic treatment? *

Yes

If yes, which parent(s)? At which office(s)?

Does the patient experience pain in the jaw joint? *

Yes

If yes, right and/or left side?

Does the patient have clicking in the jaw?

Yes

If yes, how often?

Has the patient ever been diagnosed with having jaw joint (TMJ) problems? *

Yes

If yes, when? What has been done?

Does the patient chew on pens, pencils, fingernails, etc.? *

Yes

Does the patient play a contact sport? *

Yes

If yes, which sport?

Does the patient play a wind/brass instrument? *

Yes

If yes, which instrument?

When was the patient last seen by their dentist? *

What was done at the last dental visit? *

When is the patient scheduled to return to their dentist? *

How often does the patient see their dentist? *

**If the patient is currently experiencing pink eye, strep throat, mononucleosis, or another contagious illness, please contact our office before the new patient consultation to reschedule.

I understand that the information I have given is correct to the best of my knowledge, and it is my responsibility to inform the office of any changes in the health status of the patient.

Authorization is hereby granted for the orthodontic consultation and any necessary dental services that the patient may have during diagnosis and treatment with my informed consent.

Name (First & Last) *

Date *

Relationship to Patient

Legal Guardian (if different)

Insurance Benefits

Please complete the insurance information below and bring it with you to your appointment.

Primary Insured

Insured Name

Insured Birthdate

Employer

Insurance Company

Group/Plan/Policy #

ID/Certificate #

Coverage %

Lifetime/Yearly Limit

Secondary Insured

Insured Name

Insured Birthdate

Employer

Insurance Company

Group/Plan/Policy #

ID/Certificate #

Coverage %

Lifetime/Yearly Limit

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