New Patient Form - Woodlawn Orthodontics

The fields marked by star (*), are required and must be filled out.
If you have any question or need clarification regarding the form, please do not hesitate to call our office at 519-963-7788.
Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.

Last Name

First Name

Preferred Name

Date of Birth

Gender

Address

City

State

Zip Code

Phone

Email

Dentist Name

Dentist Phone

Physician Name

Physician Phone

Emergency Contact Name

Relationship

Phone

Referred by

Preferred ways to be contacted for appointment reminders:

Phone

Email

Text (SMS)

MEDICAL AND PERSONAL QUESTIONS

What are the main concerns you would like orthodontics to correct or for seeking out an orthodontic consultation?

Have you ever visited an orthodontist before?

Yes

No

Have you ever been treated by an orthodontist?

Yes

No

Are you currently taking any prescription or over-the-counter medications?

Yes

No

If yes, please list names with the dosage:

Have you ever had any serious illness or operations?

Yes

No

If yes explain:

Do you have any allergies, sensitivities, or adverse reactions?

Yes

No

If yes explain:

Does anyone in your family have any nickel or metal allergies or sensitivities?

Yes

No

If yes explain:

Have you ever had a blood transfusion?

Yes

No

If yes, give approximate dates:

Are you currently being treated by a physician?

Yes

No

If so why:

Do you have speech problems?

Yes

No

If so, explain:

Is there anything we should know before treating you?

Yes

No

If yes, describe:

How often do you floss and brush your teeth?

How would you describe your current oral health?

Excellent

Good

Fair

Poor

Inherited dental characteristics:

Neurodevelopment conditions:

Yes

No

If yes, explain:

**PATIENT CONSENT * (Required)**

I understand that the information I have given today is correct to the best of my acknowledge. I also understand that this information will be held in strict confidence and it is my responsibility to inform the office of any changes to my medical status

I hereby authorize the release of any information pertaining to the medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Date

* Notes:

Once done, please hit “Submit” button and wait for confirmation message to make sure the form has been successfully submitted.
If you’ve not filled any required field, form will not be submitted and required fields will be shown in red to be filled.
If you’ve filled all required fields, a confirmation message will be shown; and, a copy of the form will be sent to your email as well.

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Woodlawn Orthodontics
9 Woodlawn Rd E #301,
Guelph, ON, N1H 0C1

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reception@woodlawnortho.ca

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519-963-7788

HOURS OF OPERATION

Monday:	9:00 am - 5:00 pm
Tuesday:	9:00 am - 5:00 pm
Wednesday:	9:00 am - 5:00 pm
Thursday:	9:00 am - 5:00 pm
Friday:	9:00 am - 5:00 pm
Saturday:	Closed
Sunday:	Closed