Patient Forms

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Help Us Help You!

Coming to the orthodontist for the first time can be daunting – help us get some of the anxiety out of the way by taking care of some information gathering before you arrive. We can get you in and out of Taylor Smiles comfortably and efficiently with a little help from you.

Please prepare for your first appointment by completing our patient information forms. Download and complete at home, then bring them with you to your first appointment.

Patient Info

Patient's Last Name

First Name

Middle Initial

Title

If other, preferred title

I prefer to be called

Birth Date

Sex

Identify as:

Home Address

City

Province

Postal Code

Cellular Number

Home Number

Work Number

Email Address

Occupation

Employer

Who referred you to this office?

Who first noticed the need for orthodontic care?

Reason for Orthodontic Consultation:

Have you had a previous consultation

If yes, when?

Closest Relative

Spouse or closest relative's name:

Relationship to patient:

Home Address

City

Province

Postal Code

Cellular Number

Home Number

Work Number

Email Address

Dentist / Physician

Patient's Dentist

Address, City, Province

Last Seen

Reason

Next Appointment

Other dentists/dental specialists now being seen:

Name

City, Province

Name

Family Doctor

Address, City, Province

NIHB Insurance

Do you have Indian Status?

If yes, please provide the following information.

Band Name

Band Number

Full name (as appears on card)

Birth Date

Medical & Dental History

Please check which conditions you have or have been treated for

Please list all current and recent medications below:

Medication

Reason

Medication

Reason

Medication

Reason

Please list any current or previous major illnesses that were not mentioned above:

Please ensure that you have included ALL medications & treatments including bisphosphonates, chemotherapy, radiotherapy, corticosteroid and any immune suppressants.

Any allergies to medications?

If yes, please indicate:

Any allergies to metals/latex?

If yes, please indicate:

Do you / did you have any of the following?

Tonsils and/or adenoids have been removed?

If yes, please indicate:

Any injuries to the face, mouth or teeth?

If yes, please indicate:

Thumb/finger sucking habit?

If yes, please indicate:

Speech problems that you would like to address?

If yes, please indicate:

Clicking or discomfort in the jaw?

If yes, please indicate:

Grinding or clenching of teeth?

If yes, please indicate:

Difficulty in chewing?

If yes, please indicate:

Extensive dental work or gum problems?

If yes, please indicate:

Are you concerned or have reservations about?

Co-operation for approximately 2 years?

Wearing braces?

Appearance of your face, lips, gums, or teeth?

Contact Us

Office

Monday – Thursday
8:30 – 4:30

Call Us

1.709.637.6453

Email

info@
taylorsmiles.ca

Location

343 O’Connell Dr. Corner Brook, NL A2H 7V3, Canada

1.709.63SMILE (7-6453)

[email protected]

Patient Forms

Help Us Help You!

Contact Us

Office

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