Forms Test | King & Knowlton Orthodontics

Child Patient Information

Step 1 of 2

50%

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Address(Required)

City(Required)

Postal Code(Required)

Home Phone #

Father's Name

Father's Occupation

Father's Cell #

Mother's Name

Mother's Occupation

Mother's Cell #

Email(Required)

Parents Marital Status

Single

Married

Separated

Divorced

Widow(er)

Child Lives With

Mother

Father

Other Guardian

Dental History

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your child’s orthodontic care.

Dentist's Name(Required)

Frequency of Dental Checkups

Twice a year

Once a year

Only if a problem exists

Date of Last Visit

MM slash DD slash YYYY

Is there any unfinished care to be completed with your child's dentist?

Yes

Explain (Unfinished Care)

Has your child had any facial or dental injuries?

Yes

Explain (Facial/Dental Injuries)

Is there any history of thumb or finger sucking?

Yes

Explain (Thumb/Finger Sucking)

Has there been any change in your child's bite or dental alignment recently?

Yes

Explain (Bite/Alignment Change)

History (Select all that apply)

Clenching teeth

Muscular soreness around head & neck

Jaw joint soreness

Jaw joint popping

Grinding teeth

Headaches (more than normal)

Jaw joint clicking

Ringing in ears

Speech problems (if so, which sounds?)

Growth Information (Patients Under 16 Years of Age)

Because growth can be an important factor in orthodontic treatment planning, please answer the following:

Has your son or daughter reached puberty?

Yes

Girls – Has she started menstruation?

Yes

Boys – Has his voice changed?

Yes

Child's Height

Father's Height

Mother's Height

Names and Ages of Brothers and Sisters

Have either sibling or parents had orthodontic treatment?

Yes

Explain (Orthodontic Treatment History)

Physician's Name

Is your child currently under a physician's care?

Yes

Explain (Physician's Care)

Is your child currently taking any medications?

Yes

Explain (Medications)

Is your child allergic to any medications?

Yes

Explain (Allergies)

Have your child's tonsils or adenoid been removed?

Yes

Explain (Tonsils/Adenoid)

Has your child been in a risk group for AIDS?

Yes

Explain (AIDS Risk)

Please check if your child has had any of the following conditions:

Heart Murmur

Hepatitis

Emotional Problems

Heart Surgery

Diabetes

Nervous/Anxious

Rheumatic Fever

Kidney Disease

Cancer

Endocrine Disorders

Tuberculosis

Bone Disorder

Prolonged Bleeding

Bronchitis

Growth Disorder

Anemia/Blood Disorders

Asthma

Herpes (Fever blisters)

Heart Valve Defect

Epilepsy

Tonsilitis

Hives/Rash

Fainting

Does your child have any allergies? (Please identify)

Is there any other condition or problem that you think we should know about?

Personal Information Consent Form

We are committed to protecting the privacy of our patient's personal information to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers and e-mail addresses (collectively referred to as "Contact Information"). Contact Information is collected and used for the following purposes.

To open and update patient files
To invoice patients for orthodontic services, to process credit card payments and issue receipts, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To send reminders to patients concerning the need for further orthodontic examination and treatment
To send patients informational material about our orthodontic practice

Contact Information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patient's behalf.

Financial information may be collected in order to make arrangements for the payment of orthodontic services.

We collect information from our patients about their health history, their family health history, physical condition and orthodontic treatment (collectively referred to as "Medical Information"). Patient's Medical Information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic treatement.

Patient's Medical Information is disclosed:

To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patient's behalf.
To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

If we are ever considering selling all or part of our orthodontic practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information.

Dentists and dental specialists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

Consent

I consent to the collection, use and disclosure of my personal information as set out above.

Adult Patient Information

Please fill out all required information. All information will be kept strictly confidential.

Step 1 of 2

50%

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Sex(Required)

Address(Required)

City(Required)

Postal Code(Required)

Home Phone #

Cell #

Work Phone #

Occupation

Email(Required)

Marital Status

Single

Married

Separated

Divorced

Widow(er)

Dental History

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your orthodontic care.

Dentist's Name(Required)

Frequency of Dental Checkups

Twice a year

Once a year

Only if a problem exists

Date of Last Visit

MM slash DD slash YYYY

Is there any unfinished care to be completed with your dentist?

Yes

Please Explain (if Yes)

Have you had any facial or dental injuries?

Yes

Please Explain (if Yes)

Have you noticed any change in your bite or dental alignment recently?

Yes

Please Explain (if Yes)

Have you had any previous orthodontic treatment?

Yes

Please Explain (if Yes)

Please check if there is a history of:

Clenching teeth

Muscular soreness around head & neck

Jaw joint soreness

Jaw joint popping

Grinding teeth

Headaches (more than normal)

Jaw joint clicking

Ringing in ears

Speech problems (if so, which sounds?)

Physician's Name

Are you currently under a physician's care?

Yes

Explain (if Yes)

Are you currently taking any medications?

Yes

Explain (if Yes)

Are you allergic to any medications?

Yes

Explain (if Yes)

Have your tonsils or adenoid been removed?

Yes

Explain (if Yes)

Have you been in a risk group for AIDS?

Yes

Explain (if Yes)

Please check if you have had any of the following conditions:

Heart Murmur

Heart Surgery

Rheumatic Fever

Endocrine Disorders

Prolonged Bleeding

Anemia/Blood Disorders

Heart Valve Defect

Hives/Rash

Hepatitis

Diabetes

Kidney Disease

Tuberculosis

Bronchitis

Asthma

Epilepsy

Fainting

Emotional Problems

Nervous/Anxious

Cancer

Bone Disorder

Growth Disorders

Herpes (Fever blisters)

Tonsillitis

Do you have any allergies? (Please identify)

Is there any other condition or problem that you think we should know about?

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted or required by law.

We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers and e-mail addresses (collectively referred to as “Contact Information”). Contact Information is collected and used for the following purposes:

To open and update patient files
To invoice patients for orthodontic services, to process credit card payments and issue receipts, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To send reminders to patients concerning the need for further orthodontic examination and treatment
To send patients informational material about our orthodontic practice

Contact Information is disclosed to third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patients’ behalf.

Financial information may be collected in order to make arrangements for the payment of orthodontic services.

We collect information from our patients about their health history, their family health history, physical condition, and orthodontic treatment (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing orthodontic treatment.

Patients’ Medical Information is disclosed:

To third-party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of orthodontic treatment or has asked us to submit a claim on the patients’ behalf.
To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion.
To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion.
To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment.

Dentists and dental specialists are regulated but the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest.

Consent(Required)

I consent to the collection, use and disclosure of my personal information as set out above.