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Patient Intake: Children and Adolescents Under The Age of 18

Please complete your intake form as fully as possible. Fields that LOOK LIKE THIS are required. If you have any questions or difficulties, please contact us. It takes most patients about 5-10 minutes to complete the form; please note that you cannot save a “draft” or partially-completed form, and should plan to complete your form in one session.Thank You for helping us conserve natural resources and save you time at your appointment!

Patient Information:
  • First: Last:  female male
  • Date of Birth: Extra-curricular activities: School:
Parent/Guardian Information:
  • Parent/Guardian Name: Second Parent/Guardian:
  • Parent's Marital Status:
  • Address: City: Province: Postal Code:
  • Please provide at least one: Mobile phone: Home phone: Work phone:
  • Email:
  • By checking this box: , I affirm that I am one of the legal parents/guardians listed above, and authorize Dr. Ward to provide a clinical orthodontic examination and radiographic & photographic documentation for my child, the PATIENT listed here.
    • Consultation Questions for New-Patients / Parents:
    • Consultation Date: Who may we thank for referring you?
    • If you weren't referred, how did you hear about our office?
    • Why have you and/or your child decided to get an orthodontic consult?
    • Reason for today's visit (yours/your-child's primary concern):
    • Your/your-child's secondary concerns:
    • Patient's Level of anxiousness about visiting the dentist/orthodontist:

      If greater than 3, please share your feelings:
    • What questions would you like to have answered at your initial appointment?
    • What would you/your-child like to see happen with treatment?
    • What do you/your-child think will be the greatest benefit from orthodontic treatment?
    • Is there anything else you would like us to know before your visit?:
    Dental History
    • Who is your family dentist:
    • Date of your last Dental check-up:
    • Date of your last professional cleaning:
    • Have you had orthodontics in the past? No Yes  If yes, what was done?
    • Indicate any history of (check all that apply); If checked, please explain each:
    •  Thumb/finger sucking
    •  Injury to face or teeth
    •  Tongue and/or swallowing problems
    •  Speech problems
    •  Tonsils removed
    •  Crowns/Bridges
    •  Fillings
    •  Root canals
    •  Grinding and/or clenching of teeth
    •  History of wearing a mouthguard at night
    •  History of Periodontal disease
    • If checked, please explain. Airway:
    •  While Awake: Mouth breathing preferred to nose breathing
    •  While Asleep: Mouth breathing preferred to nose breathing
    • If checked, please explain. Sleeping pattern:
    •  Move around a lot
    •  Usually takes less than 10 minutes to fall asleep
    •  Snoring
    •  Obstructive Sleep Apnea
    • If checked, please explain. Pain / Symptoms:
    •  Tooth pain/sensitivity
    •  Jaw joint pain
    •  Popping/clicking in jaw joint(s)
    •  Jaw muscle stiffness
    •  Head/Neck muscles stiffness
    •  Neck pain
    •  Headaches
    • If checked, please explain. Behavior:
    •  Restless: Inability to sit still
    •  Short attention span
    • School performance: A's B's C's D's 
    Medical History
    • Family Physician: Date of last medical checkup:
    • Are you currently under medical care; Including chiropractor, physiotherapist, massage therapist?
    • If yes, please explain:
    • Have you ever been hospitalized?
    • If yes, please explain:
    • Are you taking any medications or supplements?
    • If yes, please explain:
    • Do you have any drug or food allergies?
    • If yes, please explain:
    • Indicate any history of (check all that apply); If checked, please explain each:
    •  Motor vehicle accident
    •  Trauma to the head/neck region
    •  Asthma
    •  Depression
    •  ADHD
    •  Rheumatic fever
    •  Joint replacement
    •  Diabetes
    •  Hepatitis
    •  HIV positive
    •  Prolonged bleeding
    •  Epilepsy or seizures
    •  Osteoporosis
    •  Lupus
    •  Cancer
    •  Other
    Insurance Information:
    • Insurance Plan 1:
    • Employee's Name:
    • Company Name:
    • Insurance Company:
    • Group/Policy Number:
    • Certificate/I.D./S.I.N Number:
    • Date of Birth (MM/DD/YY):
    • Relationship to Patient:
    • Insurance Plan 2:
    • Employee's Name:
    • Company Name:
    • Insurance Company:
    • Group/Policy Number:
    • Certificate/I.D./S.I.N Number:
    • Date of Birth (MM/DD/YY):
    • Relationship to Patient:
    Legal Release and Consent
    • Orthodontic Office Personal Information Consent: Please download and review this legal document.
      Personal Information Consent: By checking this box, I acknowledge that I have reviewed and agree to the terms of the Personal Information Consent form as regards my child, the PATIENT listed here.

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