Test Braces | Dentists In Edmonton & Area Smiles Dental Group

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Thank you for choosing Braces Orthodontics! We look forward to seeing you again!

Save time by filling out the medical form below before you arrive at the clinic.

Braces NP

Patient Biographical Information

Name(Required)

First Last

Preferred Name (Optional)

Email(Required)

Date of Birth(Required)

Phone

Cell Phone(Required)

Sex(Required)

Male

Female

Preferred Pronouns:

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

How Did You Hear About Us?

Google

Social Media (Facebook/Instagram/etc)

Family/Friend

Live in the Area

Parent/Guardian Biographical Information

Relationship to Patient:(Required)

Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

Email(Required)

Does this Parent/Guardian and the Patient Share the Same Address?(Required)

Yes

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Would You Like to Add Another Parent/Guardian?(Required)

Yes

Second Parent/Guardian Biographical Information

Relationship to Patient:(Required)

Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

Email(Required)

Does this Parent/Guardian and the Patient Share the Same Address?(Required)

Yes

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Dental History

Dentist Name:(Required)

Last Routine Dental Checkup(Required)

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Last Routine Dental Cleaning(Required)

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Has the Patient Undergone an Orthodontic Consultation or Treatment Before?(Required)

Yes

When was the Consult or Treatment?(Required)

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

What is Your Main Orthodontic Concern?(Required)

Medical History

Are you being treated for any medical condition at present or within the past two years?(Required)

Yes

What is Your Condition?(Required)

Have you been hospitalized in the past two years?(Required)

Yes

When was Your Last Visit to a Physician?(Required)

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Last Complete Physical Examination?(Required)

Less than 12 Months Ago

1-2 Years Ago

3-4 Years Ago

More than 5 Years Ago

Have you recently, or are you presently, taking any PRESCRIPTION or NON-PRESCRIPTION drugs including vitamins or naturopathic substances? Please list:

(Use the + Button to Add More)

Have you ever reacted adversely to any of the following?(Required)

Please Indicate Any Medicine NOT Listed Above

Have you ever been advised against taking any specific type of medication?(Required)

Yes

Allergies: do you have any of the following?

Asthma

Hay Fever

Food Allergies

Metal/Latex Allergies

Skin Rashes

Hives

Please Indicate Any Allergic Conditions NOT Listed Above

Do any of these allergic conditions result in:

Headaches

Nausea

Swelling

Shortness of Breath

Chest Constriction

Can You Tell Us a Bit More?(Required)

Have you been advised by your Medical Doctor or Dentist to take antibiotics prior to dental treatment?(Required)

Yes

Do you bleed EXCESSIVELY from cut or injury, or bruise easily?(Required)

Yes

Do you ankles, feet or hands swell?(Required)

Yes

Are you thirsty much of the time or urinate more than 6 times per day?(Required)

Yes

Has your weight, appetite or energy level changed dramatically recently?(Required)

Yes

Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?(Required)

Yes

Have you tested HIV positive, or come in contact with the AIDS virus?(Required)

Yes

Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?(Required)

Yes

Have you ever had any injury or surgery to your face or jaws?(Required)

Yes

Have you had any surgeries?(Required)

Yes

Do you smoke or use any other forms of tobacco?(Required)

Yes

Are you alcohol and/or drug dependent?(Required)

Yes

Have you received treatment for your alcohol/drug dependency??(Required)

Yes

Which of the Following Applies to You?

Is Your Cancer in Treatment or in Remission?(Required)

Treatment

Remission

Please Indicate Any Disease, Condition or Problem NOT Listed Above

Is There a Family History of Any of the Above Conditions?(Required)

Yes

Are You Pregnant (or Suspect You Would Be)?(Required)

Yes

Is there anything else about your health we should be made aware of?

Do you wish to speak to the Doctor privately about any problem or medical condition?

Insurance

Do You Have Insurance?(Required)

Yes

Are You the Policyholder?(Required)

Yes

Policyholder Name(Required)

First Last

Policyholder Date of Birth(Required)

Please Upload Photos of the Front and Back of Your Insurance Card:(Required)

Drop files here or

Max. file size: 3 GB.

We require your signature below to indicate your consent to perform the dental and oral procedures necessary for treatment, including the use of local anesthetic and/or relative analgesia as indicated, and that you assume responsibility for the fees associated with those procedures and finance charges if you fail to do so within adequate time

Name(Required)

Date(Required)

Signature(Required)

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Dentists in Edmonton, Mill Woods, Spruce Grove, St Albert and Sherwood Park

Our Edmonton dentists offer a wide range of dental services such as cleanings, clear aligners, dental surgeries, wisdom teeth extractions, dental implants. We even offer elective esthetic dental procedures like porcelain veneers, tooth-coloured (mercury-free) fillings, in-office teeth whitening, as well as many others.

We Accept the Canada Dental Care Plan! Click Here to Learn More

We Accept the Canada Dental Care Plan (CDCP)! Click Here to Learn More

Save Time at the Clinic!

Braces NP

Patient Biographical Information

Parent/Guardian Biographical Information

Second Parent/Guardian Biographical Information

Dental History

Medical History

Insurance

Dentists in Edmonton, Mill Woods, Spruce Grove, St Albert and Sherwood Park

Dental Clinics

Smile Dental Group