Child Health History Form – Tolmie Orthodontics

Tolmie Orthodontic Patient In-Take Form (Child)

Patient's First Name

Patient's Last Name

Patient Gender

Date of Birth

Address

Address Line 1

City

Postal Code

Home Phone no.

Referred By

List any sports, hobbies or interests

Do you have orthodontic insurance coverage?

Yes

Policy Holder Name

Employer

Mother's Name (first and last)

Home Address (if different from above)

Address Line 1

City

Postal Code

Work Phone no.

Cell Phone no.

How do you prefer to be contacted? Check all that apply

Father's Name (first and last)

Home Address (if different from above)

Address Line 1

City

Postal Code

Work Phone no.

Cell Phone no.

How do you prefer to be contacted? Check all that apply

Person(s) responsible for payments on account

Mother

Father

Other

If you selected 'other' above, please list their first and last name

Name and age of siblings (of patient)

Patient's Family Physician

Phone no. of Physician

Is your child under a physician's care at present?

Yes

If you selected 'yes' above, please describe

Is your child being treated for any medical conditions?

Yes

If you selected 'yes' above, please describe

Is your child currently taking any prescription or non-prescription medications?

Yes

Is your child allergic to any medications (e.g, Penicillin, sulfa drugs, pain relievers)? Or Latex?

Yes - Both

Yes - Medications

Yes - Latex

Has your child ever had any serious illness?

Yes

If you selected 'yes' above, please describe:

Has your child ever been hospitalized or undergone any type of surgery?

Yes

If you selected 'yes' above, please describe:

Has your child ever had prolonged bleeding following a tooth extraction or minor injury?

Yes

Are there any conditions or diseases that run in your family? E.g. diabetes, heart disease, cancer

Does your child smoke or use any tobacco products?

Yes

If you selected 'yes' above, how much?

For females: is your child pregnant, or suspect that they may be?

Yes

Does your child have or have ever had any of the following? Check all that apply

If you selected selected any of the above, please give pertinent details:

Are there any other medical conditions the doctor should be aware of?

Main reason you are seeking orthodontic treatment:

Patient's Dentist:

Date of last dental checkup

How often does your child visit the dentist? Brush? Floss?

Is your child currently experiencing any dental pain?

Yes

Have you been informed of any missing or extra permanent teeth?

Yes

Has your child ever had any permanent teeth removed, including wisdom teeth?

Yes

If you selected 'yes' above, how many?

Has your child ever had previous orthodontic treatment or consultation?

Yes

If you selected 'yes' above, when? Doctor's name?

Any injuries to the face, teeth or mouth?

Yes

If you selected 'yes' above, please describe:

Do any untreated cavities exist?

Yes

Is there currently or any history of jaw or facial muscle pain?

Yes

Is there currently or any history of pain in your child's jaw joints?

Yes

If you selected 'yes' above, when?

Is there currently or any history of difficulty in opening or closing your child's jaws?

Yes

Does your child clench or grind your teeth?

Yes

Do you find that your child breathes predominantly through the mouth, or with their mouth open?

Yes

Has your child ever sucked their thumb or finger?

Yes

If you selected 'yes' above, until what age?

Does your child want orthodontic treatment?

Yes

Are there any other oral conditions that the doctor should be aware of?

I have read and understand the above questions and 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 medical/dental status.

I agree

As your child's guardian, please type your first and last name below as digital signature of this form:

Date

Reviewed by Doctor (Please leave blank)

Date / Time

Please thoroughly read through the 'Consent for Collection, Use and Disclosure of Personal Information' below and check this box if you agree.

Privacy of information is an important part of how our office provides high-quality care. We understand the importance of protecting your information. We are committed to collecting, using and disclosing it responsibly. We also try to be as open and transparent as possible about the way we handle your information.

In this office, Docters act as the Privacy Information Officer.

All staff members who come in contact with your personal information have been trained in the appropriate uses and protection of your information. They are aware of its sensitive nature.

Our goals are to ensure that:
We only collect necessary information and we only share information with your consent; storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; our privacy protocols comply with privacy legislation and the standards of our regulatory body, the RCDSO, and the law.

How we collect, use and disclose patients' personal information:

This office will collect, use and disclose information about you for the following purposes:

to assess your health needs, advise you of treatment options and to deliver safe, effective, and efficient patient care
to identify and to ensure continuous high quality service
to establish and maintain communication with you and to book and confirm appointments
to communicate with your general dentist and your other health-care providers, including dental specialists and physicians
to allow us to efficiently follow-up for treatments, care and billing
to provide the efficiency of our computerized check-in process your name must be displayed
for teaching and demonstrating purposes on an anonymous basis
to complete and submit dental claims for third party adjudication and payment
to comply with legal and regulatory requirements, including the delivery of patients' charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
to permit potential purchasers, brokers, accountants or advisors to evaluate our practice
to deliver your charts and records to the dentist's insurance carrier to enable the insurance company to assess liability and quantify damages, if any
to prepare materials for the Health Professions Appeal and Review Board (HPARB)
to process credit card payments, direct bank account debits and to invoice for services
to collect unpaid accounts
to assist this office to comply with all regulatory requirements
to comply generally with the law

By checking this box, you agree to the consent section of this Patient Consent Form; you agree that you have given your informed consent to the collection , use, and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue.

Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent.

When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

Our office has a privacy code; copies of this code are available on request.

Patient Consent
By checking this box I agree that I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Tolmie Orthodontics can collect, use, and disclose my personal information as set out above in the information about privacy policies.

As your child's guardian, please type your name in the field below as your digital signature to consent to the above information:

Date

Name of Witness (Please type here as signature)

Date of Witness Signature