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Orthodontic Consultation Form (Child)

Completion of this form is required for all new child 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 6

Patient's name *

First

Last

Patient's birthdate (MM/DD/YYYY) *//

Age *

Gender *

Female
Male
Non-binary

Pronouns *

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

How shall we address the patient? *

Patient's address *

Address Line 1

Address Line 2

City

Province

Postal Code

School *

Does your child 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.

Does your child see their dentist for regular check-ups/cleanings? *

Does your child currently have a family doctor? *

Doctor's name *

Doctor's office name and/or location

This ensures we find the correct doctor 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

Siblings' names and ages

Parent / Guardian #1

Including consent for a minor. A second caregiver can be added below.

Your name *

First

Last

i.e. who is filling in this form for the child patient

Relationship to patient *

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

Home phone (optional)

Secondary

Occupation

Same address as patient? *

Caregiver's address *

Address Line 1

Address Line 2

City

Province

Postal Code

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

Signature *

This signature applies directly to the authorization provided above

Important: Authorization will be required before treatment can be provided, but this can be discussed further at the patient's 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 the patient's dentist whenever possible, to limit their radiation exposure.

Please provide comments about your selection above *

Parent / Guardian #2

Including consent for a minor.

Is there another parent / legal guardian that should be included in our correspondence AND that we will require consent from before providing orthodontic treatment for the patient? *

Caregiver's name *

First

Last

Relationship to patient *

Mobile phone *

Primary

Email address *

Do you consent to, and are you permitted to consent to this person receiving electronic messages (email / text messages) from Authentic Orthodontics? *

Yes
No
Unsure

Without consent, their experience may be negatively impacted.
Messages may include: payment receipts, appointment reminders (by email, or text when permitted), and infrequent updates from our practice.

Additional details regarding electronic communication *

e.g. should we obtain their consent directly, or are there certain messages that are permitted, while others aren't?

Should this person receive appointment reminders by text message? *

Yes
No, but please email them
No, please don't send them reminders

Should this person receive appointment reminders by email? *

We can only send text message reminders to 1 person, and Parent / Guardian #1 was designated for this already, above.

Home phone (optional)

Secondary

Occupation

Same address as patient? *

Patient Health Information

What is the primary reason for seeking orthodontic treatment for your child? *

Has your child reached puberty? *

Has menstruation started? *

Voice changed? *

Have you noticed a rapid rate of growth in the past year? *

Child's height *

Does your child have, or have they had, any health conditions or serious illnesses that we should be aware of? *

Health condition details *

Is your child taking any medications?

Medication details *

Does your child have a Latex sensitivity or allergy? *

Has your child had a recent exposure to any communicable infectious diseases? *

Infectious disease details *

Does your child have an allergy to, or have they ever had a bad reaction to any of the following:

Ibuprofen
Penicillin
Aspirin
Codeine
Local anesthetics
Other...

Additional allergy details *

Does your child experience any of the following:

Frequent colds
Difficulty breathing through nose
Snoring
Grinding teeth
Thumb/finger sucking habit

Has your child ever had an injury to the head, neck, face, teeth or chin? *

e.g. stitches, concussion, whiplash, …

Injury details *

Has your child ever been told they require antibiotics prior to dental treatment? *

Has your child 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 child's general / dental health

Insurance Information

You may enter details for up to THREE policies.

Insurance Policy #1

Whose insurance policy is this? *

A parent / legal guardian already mentioned on this form
Someone new
I don't have any insurance policies to add

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

Yes, it is my policy
Yes, I am permitted to add this person's policy
No

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 patient *

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? *

Whose insurance policy is this? *

A parent / legal guardian already mentioned on this form
Someone new

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 patient *

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? *

Whose insurance policy is this? *

A parent / legal guardian already mentioned on this form
Someone new

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 patient *

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.

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?