Skip to content

Orthodontics
- F.A.Q.
Technologies
Achievements
Contact

Orthodontics
- F.A.Q.
Technologies
Achievements
Contact

Medical Form

Medical Intake Form

Date of Appointment

Patient Information

Last Name

First Name

Gender at Birth

Referred by

Name of Dentist

Is the patient covered under a dental insurance plan?

No Yes

Primary Address & Contact Information

Street Address 1

Street Address 2

City

Province

Postal Code

Primary Phone

Secondary Phone

Email Address

Patient Profile Information

Date of Birth

Age

Parent / Legal Guardian 1

Responsible for payment?

Relationship to Patient

Last Name

First Name

Primary Phone

Secondary Phone

Email Address

Parent / Legal Guardian 2

Responsible for payment?

Relationship to Patient

Last Name

First Name

Primary Phone

Secondary Phone

Email Address

Does the patient have a secondary address?

No Yes

Secondary Address

Street Address 1

Street Address 2

City

Province

Postal Code

Medical History

Are you currently, or have you ever suffered from:

Arthritis

No Yes

Anemia

No Yes

Asthma

No Yes

Diabetes

No Yes

Dizziness

No Yes

Ear Aches

No Yes

Epilepsy

No Yes

Fainting Spells

No Yes

Frequent Headaches

No Yes

Heart Disease

No Yes

High or Low Blood Pressure

No Yes

Kidney / Liver Disease

No Yes

Nervous Disorders

No Yes

Osteoporosis

No Yes

Radiation Treatment (Cancer)

No Yes

Rheumatic Fever

No Yes

Thyroid Problem

No Yes

Tuberculosis

No Yes

Do you take any bisphosphonates?

No Yes

Do you snore or have you been told you do?

No Yes

Are you currently under a doctor's care?

No Yes

If YES, for what reason?

Name your physician

Are you currently taking any medications, or have you taken any in the last six months?

No Yes

If YES, which medication(s)?

Are you HIV Positive?

No Yes

Do you bleed abnormally when injured?

No Yes

Do you have frequent colds?

No Yes

Have your tonsils and/or adenoids been removed?

No Yes

If YES, when?

Do you suffer from any allergies (respiratory, food or dietary, medication or other)?

No Yes

If YES, please specify

Please add anything else you'd like to mention about your medical history:

Dental History

Date of your last Dentist's Examination

How many times a year do you visit the dentist?

How many times do you brush your teeth per day?

Have you ever had an accident to your face?

No Yes

Have you ever had an accident to your head or jaw bones?

No Yes

Did you ever have an orthodontic treatment?

No Yes

Do you hear any cracking noises in your jaw joints?

No Yes

Do you experience painful or bleeding gums?

No Yes

Have you undergone treatments for your gums (grafts, deep scaling)?

No Yes

Do you bite your finger nails?

No Yes

Do you grind your teeth?

No Yes

Do you chew gum for more than 15 minutes per day?

No Yes

Do you still suck your thumb?

No Yes

Do you wish to correct the aesthetic appearance of your teeth?

No Yes

Have you ever seen a speech therapist?

No Yes

Has any other member of the family had an orthodontic treatment?

No Yes

If YES, indicate the name of the professional who did the correction:

By clicking on the "Submit" button below, you acknowledge that you have read and accept our Privacy Policy.

Need more information about orthodontic options?

Reach out - we're happy to schedule an appointment.

Contact Us

Opening Hours:
Tuesday to Thursday: 8am to 5pm
Friday: 8am to 12pm

Saturday, Sunday & Monday: Closed

1101 Jean Talon East
Montréal, QC H2R 1V8

(514) 948-1101
info@drorthodontistes.com

Cookie Consent

To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options
Manage services
Manage {vendor_count} vendors
Read more about these purposes

View preferences

{title}
{title}
{title}