New Patient Form

Welcome! We're so glad you've chosen our team at Paleczny Orthodontics to help you achieve your smile goals. Please use one of the options below to complete our New Patient Form.

Option 1

Complete Online

Complete and submit the online form.

Online Form

Option 2

Print & Complete

Bring the completed form with you your first appointment.

Downloadable Form

Option 3

Complete on Arrival

If you prefer, fill out the form when you get to our clinic.

Patient Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone (Primary) *

Phone (Secondary)

Address *

City *

Postal Code *

Family Physician

Family Dentist

Does the patient have any relatives who have had treatment in this practice? *

Yes

Unsure

Parent / Guardian Information

If completing this form for a minor, please complete parent / guardian information below.

First Name *

Last Name *

Relationship to Patient *

Phone (If different from above)

Address (If different from above)

Medical History

Have you had any previous orthodontic treatment? *

Yes

Are you currently taking any medication? *

Yes

If yes, please list *

Are you in a high risk group for HIV Infection? *

Yes

Allergies *

Yes

Do you have a history of any serious illness? *

Yes

Have you had injuries to the head? *

Yes

Have you been informed of any missing or extra teeth? *

Yes

Does the patient have a history of any of the following? (Check all that apply) *

Anemia

Bone Disorders

Diabetes

Epilepsy

Fainting or Dizziness

Heart Trouble

Gland or Endocrine Problems

Rheumatic Fever

Nervous Disorders

Congenital Abnormalities

Emotional Disorders

Tuberculosis

Liver Problems

Blood Disorders

Hepatitis

HIV Infection

Prolonged Bleeding

Kidney Problems

Frequent Colds

Asthma

Ear Infections

Chronic Nasal Obstruction

Mouthbreathing

Adenoid Problems

Tonsillitis

Tongue thrusting

Tooth grinding or clenching

Headaches (frequent)

Muscular soreness around head and neck

Jaw joint clicking of popping

Thumbsucking

Finger sucking

Lip biting or sucking

N/A

Have you received treatment for any of the above problems? *

Yes

Have your tonsils been removed? *

Yes

Unsure

Have your adenoids been removed? *

Yes

Unsure

Dental History

Do you have regular dental checkups? *

Yes

Date of Last Checkup *

Tooth Brushing *

After every meal

Once per day

Twice per day

Do you floss? *

Yes

Reason for seeking orthodontic consultation? *

In accordance with Canada's federal anti-spam regulations, I accept to be contacted through email by Paleczny Orthodontics. *

Yes

I hereby acknowledge that the health history provided is correct. *

Yes my information is correct

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