(905) 281-8200265 Enfield Place, Suite 100B Mississauga25 King George Rd, Brantford, ON‎ 415 Fairview Dr, Brantford, ON

TROPICAL ORTHODONTICS

Braces | Orthodontic Specialists

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New Patient Form for Adults

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New Patient Form for Adults

If you have any questions about this form please email us at info@tropicalorthodontics.com
or call us at (905) 281-8200, we will be happy to help!

Email address*

NAME:*

MALE

FEMALE

BIRTHDAY:

Age

SS #:

HOME ADDRESS:

City

Province

Postal Code

Single

Married

Divorced

Widowed

Separated

Home Phone:

Work Phone:

Cell - Other:

Ext:

Employer:

Employer’s Address:

How long there:

Occupation:

Where & when are best times to reach you?

Other family members seen by us:

General Dentist:

Lat Visit Date:

SPOUSE INFORMATION

His / Her Name:

Home Phone:

Work Phone:

Cell - Other:

Ext:

Birthday:

ORTHODONTIC INSURANCE Primary

Orthodontic Coverage:

Yes

No

Dental Coverage:

Yes

No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthday:

Insured’s ID #:

Insured’s Employer:

ORTHODONTIC INSURANCE Secondary

Orthodontic Coverage:

Yes

No

Dental Coverage:

Yes

No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthday:

Insured’s ID #:

In the event of an emergency, is there someone who lives near you that we should contact?

His / Her Name:

Home Phone:

Relation:

Work Phone:

MEDICAL HISTORY

Do you have a personal Physician

Yes

No

Physician’s Name:

Phone:

Date of last Visit:

Your current physical health is:

Good

Fair

Poor

Are you currently under the care of a physician?

Yes

No

Please explain:

Are you taking any prescription / over-the-counter drugs?

Yes

No

For Women: Are you using a prescribed method of birth control?

Yes

No

Are you pregnant?

Yes

No

Are you nursing?

Yes

No

Have you ever ad any of the following diseases or medical problems?

Abnormal Bleeding

Yes

No

Anemia

Yes

No

Artificial Bones / Joints / Valves

Yes

No

Asthma / Arthritis

Yes

No

Blood Transfusion

Yes

No

Cancer / Chemotherapy

Yes

No

Congenital Heart Defect

Yes

No

Diabetes

Yes

No

Difficulty Breathing

Yes

No

Drug / Alcohol Abuse

Yes

No

Emphysema

Yes

No

Epilepsy / seizures / Fainting

Yes

No

Fever Blisters / herpes

Yes

No

Glaucoma

Yes

No

Heart Attack / stroke

Yes

No

Heart Murmur

Yes

No

heart Surgery / Pacemaker

Yes

No

Hemophilia

Yes

No

Hepatitis

Yes

No

High / Low Blood Pressure

Yes

No

HIV+ / AIDS

Yes

No

Hospitalized for Any Reason

Yes

No

Kidney Problems

Yes

No

Mitral Valve Prolapse

Yes

No

Psychiatric Problem

Yes

No

Radiation Treatment

Yes

No

Rheumatic / Scarlet Fever

Yes

No

Sever / Frequent Headaches

Yes

No

Shingles

Yes

No

Sickle Cell Disease / Traits

Yes

No

Sinus Problems

Yes

No

Tuberculosis (TB)

Yes

No

Ulcers / Colitis

Yes

No

Venereal Disease

Yes

No

Please List any medical condition(s) that you have ever had:

Are you allergic to any of the following?

Aspirin

Yes

No

Any Metals / Plastics

Yes

No

Codeine

Yes

No

Dental Anesthetics

Yes

No

Erythromycin

Yes

No

Latex

Yes

No

Penicillin

Yes

No

Tetracycline

Yes

No

Other

Yes

No

Please list any other drugs / materials that you are allergic to:

DENTAL HISTORY

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

Have you ever had or been evaluated for for orthodontic treatment?

Yes

No

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes

No

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?

Yes

No

Your current dental health is:

Yes

Fair

No

Do you like your smile?

Yes

No

Have you ever had an injury to your:

Mouth

Teeth

Chin

Gums ever bleed?

Yes

No

Do you have any speech problems?

Do you generally breath through your mouth?

Yes

No

If yes While Awake?

While Asleep?

Do you have any missing or extra permanent teeth?

Yes

No

Have you ever taken Phen-Fen?

Yes

No

Have you ever taken Fosamax, or any other bisphosphonate?

Yes

No

Do you smoke or use tobacco in any form?

Yes

No

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 service that I may need during diagnosis and treatment with my informed consent.

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mail: info@tropicalorthodontics.comTel: (905) 281-8200

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