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745 Bloor St W
29 Elm St
Meet the Team
Services
General Dentistry
Orthodontics in Toronto
Root Canal Therapy and Endodontics
Wisdom Teeth Extraction
Sedation Dentistry
Pediatric Dentistry
Pediatric Treatments
Infant Dental Care
Cosmetic Dentistry
Invisalign
Porcelain Veneers
Teeth Whitening
Dental Bonding
Orthodontics in Toronto
Restorative Dentistry
Surgical Treatments
All-On-4
Dental Crowns
Dental Bridges
Dentures
Onlays, Inlays and Fillings
Forms
My Invisalign Login
Ortho Consultation
New Patients
Locations
Korea Town
Dundas Square
CDCP
Jobs
Contact
Meet the Team
Services
General Dentistry
Orthodontics in Toronto
Root Canal Therapy and Endodontics
Wisdom Teeth Extraction
Sedation Dentistry
Pediatric Dentistry
Pediatric Treatments
Infant Dental Care
Cosmetic Dentistry
Invisalign
Porcelain Veneers
Teeth Whitening
Dental Bonding
Orthodontics in Toronto
Restorative Dentistry
Surgical Treatments
All-On-4
Dental Crowns
Dental Bridges
Dentures
Onlays, Inlays and Fillings
Forms
My Invisalign Login
Ortho Consultation
New Patients
Locations
Korea Town
Dundas Square
CDCP
Jobs
Contact
Emergency? Call us!
CHRISTIE PARK
ELMWOOD PARK
ORTHODONTIC CONSULTATION
ORTHODONTIC CONSULTATION:
ORTHODONTIC CONSULTATION:
PLEASE TELL US WHY YOU ARE SEEKING AN ORTHODONTIC CONSULTATION:
(Required)
How did you hear about us?
PATIENT INFORMATION
Name
(Required)
Patient First Name
Patient Middle Name
Patient Last Name
Gender
Male
Female
Date of Birth
MM slash DD slash YYYY
Home Phone
Phone
Age
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name of Dentist
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Parent
Parent/ Guardian Last, First Name
Contact Number
Email
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
MEDICAL INFORMATION
Name of Family Doctor
Contact Number
Heart Disease
(Required)
Yes
No
Infective Endocarditis
(Required)
Yes
No
Heart Defect / Repair
(Required)
Yes
No
Cancer
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Blood Disease
(Required)
Yes
No
Sleep Apnea
(Required)
Yes
No
Asthma
(Required)
Yes
No
Arthritis
(Required)
Yes
No
Tuberculosis
(Required)
Yes
No
Hepatitis A, B or C
(Required)
Yes
No
H.I.V / A.I.D.S
(Required)
Yes
No
Liver Disease
(Required)
Yes
No
Prolonged Bleeding
(Required)
Yes
No
Autism
(Required)
Yes
No
Other medical conditions (not listed above)
Other medical conditions (not listed above)
Is antibiotic medication required for dental cleanings?
(Required)
Yes
No
Have tonsils and/or adenoids been removed?
(Required)
Yes
No
(Women) Are you pregnant?
Yes
No
Have you ever taken medications for osteoporosis?
(Required)
Yes
No
List any allergies and drug sensitivities: A: Medications B: Latex C: Metal/Nickel D: Other (eg: foods/hayfever).
List any medication(s) now being taken and please give reasons.
Are there any mental health concerns?
DENTAL INFORMATION
When was the last visit to the family dentist?
Have you ever seen a Periodontist (gum specialist)?
(Required)
Yes
No
Have there been any injuries to the face, mouth or teeth?
(Required)
Yes
No
Any thumb or finger habit?
(Required)
Yes
No
Are you a mouth breather?
(Required)
Yes
No
Any speech problems?
(Required)
Yes
No
Has there been a previous orthodontic examination?
(Required)
Yes
No
Frequent canker or cold sores?
(Required)
Yes
No
Ever had braces or orthodontic treatment?
(Required)
Yes
No
Have any other family members
(Required)
Yes
No
Do gums bleed when brushing or flossing?
(Required)
Yes
No
Has there ever been treatment for a jaw joint problem, including surgery?
(Required)
Yes
No
By sharing your email with Christie Park Dental you agree to receive emails from us about appointments and newsletters, and understand that you can opt out at any time. Your email and personal information will not be shared with third parties at any time.
(Required)
Yes
No
RELEASE OF INFORMATION:
(Required)
I hereby give Christie Park Dental and/or members of the staff permission to release information concerning my dental and/or orthodontic health to my family physician, dentist or any other dental specialists as is deemed necessary. This information
includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.
I agree
Signature of Patient/Guardian
(Required)
Signature of Dentist/Orthodontist
