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Orthodontic Consultation Form (Adult)

Completion of this form is required for all new adult patients.

You can easily complete this form online, on a computer or mobile device.

It will take several minutes, and your progress can't be saved so ensure you can complete it in one sitting. Please have your insurance information handy.

Your response will be submitted to us securely and no personal details will be transferred by email.

If you have any questions, please give us a call.

- Step 1 of 4

Patient's name *

First

Last

Birthdate (MM/DD/YYYY) *

Age *

Gender *

Female
Male
Non-binary

Pronouns *

She / her
He / him
Let me type...

How shall we address you? *

Mobile phone *

Primary

Email address *

Do you consent to receive electronic messages (email / text messages) from Authentic Orthodontics? *

Without consent, your experience may be negatively impacted.
Messages may include: payment receipts, appointment reminders (by text/email, your preference), and infrequent updates from our practice.

Additional details regarding electronic communication *

e.g. are there certain messages that are permitted, while others aren't?

Would you like to receive appointment reminders by text message? *

We will send reminders by email, otherwise

Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Occupation

Home phone (optional)

Secondary

Do you currently have a dentist? *

Dentist's name *

Dentist's office name and/or location *

This ensures we find the correct dentist with the provided name.

Do you see your dentist for regular check-ups/cleanings? *

Do you currently have a physician?

Physician's name *

Physician's office name and/or location *

This ensures we find the correct physician with the provided name.

Who may we thank for referring you to our office? *

e.g. your dentist, family doctor, another patient, or perhaps you found us online

Would you like to add an emergency contact to your file? *

Person's name *

First

Last

Relationship to you *

Person's mobile phone *

In the rare case of an emergency, we will phone them at this number

Patient Health Information

What is the primary reason for seeking orthodontic treatment? *

Do you have, or have you had, any health conditions or serious illnesses that we should be aware of? *

Health condition details *

Are you taking any prescription / non-prescription drugs? *

Medication details *

Do you have a Latex sensitivity or allergy? *

Do you have an allergy, or have you ever had a bad reaction to any of the following:

Local anesthetics
Codeine
Insulin
Penicillin
Ibuprofen
Aspirin
Iodine
Metals
Other...

Additional allergy details *

Do you experience any of the following:

Frequent colds
Difficulty breathing through nose
Jaw pain
Headaches
Snoring
Grinding teeth

Have you ever (at any age) had an injury to the head, neck, face, teeth or chin? *

e.g. stitches, concussion, whiplash, ...

Injury details *

Do you currently or have you previously worn an appliance for jaw joint issues? *

Have you ever been told you require antibiotics prior to dental treatment? *

Have you ever had any abnormal bleeding associated with previous extractions, surgery or trauma? *

Bleeding details *

If applicable, please share any other information that we should know about your general / dental health

Insurance Information

You may enter details for up to THREE policies.

Insurance Policy #1

Whose insurance policy is this? *

Mine
Someone new
I don't have any insurance policies to add

Note: If you will be entering the details of your own policy, it must be entered here as Policy #1

Do you have consent to provide us with insurance information on behalf of this person? *

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's relationship to you *

Do you have the information for this policy available right now? *

Yes
No, I will need to provide it later

It is very helpful if you can enter these details now.
You will need: (a) the policy holder's birthdate and address, (b) the insurance company, (c) the group / policy #, and (d) the ID / certificate #. You may optionally upload a photo/document showing (b), (c) and (d).

Important: The details of this policy will be required at your consultation in order for us to submit a pre-authorization on your behalf for any proposed treatment.

We offer an easy, secure way for you to submit this information online at a later date, before your consultation.

Would you like an email reminder to submit this online, later? *

Okay! When you submit this form, you will receive a reminder at the email address you've already provided for yourself.

Okay, no problem! Please remember to bring this with you to the consultation.

Policy holder's birthdate *

Same address as patient? *

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #1 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Insurance Policy #2

Would you like to add a second insurance policy? *

Do you have consent to provide us with insurance information on behalf of this second person? *

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's relationship to you *

Do you have the information for this policy available right now? *

Yes
No, I will need to provide it later

Important: The details of this policy will be required at your consultation in order for us to submit a pre-authorization on your behalf for any proposed treatment.

We offer an easy, secure way for you to submit this information online at a later date, before your consultation.

Would you like an email reminder to submit this online, later? *

Okay! When you submit this form, you will receive a reminder at the email address you've already provided for yourself.

Okay, no problem! Please remember to bring this with you to the consultation.

Policy holder's birthdate *

Same address as patient? *

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #2 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Insurance Policy #3

Would you like to add a third insurance policy? *

Do you have consent to provide us with insurance information on behalf of this third person? *

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's relationship to you *

Do you have the information for this policy available right now? *

Yes
No, I will need to provide it later

Important: The details of this policy will be required at your consultation in order for us to submit a pre-authorization on your behalf for any proposed treatment.

We offer an easy, secure way for you to submit this information online at a later date, before your consultation.

Would you like an email reminder to submit this online, later? *

Okay! When you submit this form, you will receive a reminder at the email address you've already provided for yourself.

Okay, no problem! Please remember to bring this with you to the consultation.

Policy holder's birthdate *

Same address as patient? *

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #3 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Do you authorize Authentic Orthodontics to complete an orthodontic consultation, including x-rays and photographs, as necessary? *

Important: Authorization will be required before treatment can be provided, but this can be discussed further at your consultation if you prefer.

If you have concerns about x-rays being taken, please note that we only take x-rays when it's necessary and we will use recent x-rays from your dentist whenever possible, to limit your radiation exposure.

Please provide comments about your selection above *

I confirm that the information provided on this form is accurate and true to the date of completion *

Signature *

Additional details (optional)

Is there anything else we should know about the information you've provided here today?