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Health History

Patient Information

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Name(Required)
Address(Required)

Dental History

Are you happy/satisfied with your smile?(Required)
Have you ever had or been evaluated for orthodontic treatment?(Required)
Are you currently or have you ever experienced problems with their jaw joints (TMJ)?(Required)
Have you had any injuries to the face, mouth, teeth, chin?(Required)
Have you had or presently have any of the following:
Does the patient see the dentist regularly?(Required)

Medical History

Your current physical health is:
Are you currently under the care of a Physician?(Required)
Do you require antibiotics before dental treatment?(Required)
Are you taking any prescription/over the counter medications?(Required)
Do you have any allergies?(Required)
YESNO
Aids/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Cancer/Chemotherapy
Bone Disorders
Diabetes
Heart Attack/Stroke
Heart Murmur
Cerebral Palsy
Autism Spectrum
Behavioural Disorder
Nervous Disorder
Are you taking any medications for osteoporosis?
For Women: are you currently pregnant?
Collection and Disclosure of Information(Required)
I further consent to the collection, use and disclosure of my personal information for the following purposes:
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North Okanagan Orthodontics
#300 - 3126 31st Ave
Vernon, BC
T: (250) 542-4118
F: (250) 542-4652
Operating Hours: 8:30am to 5:00pm
Monday-Thursday

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