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Child History Form

Office Location

LondonSt. thomas

Patient Information

MaleFemaleNeutral

Address

Family Information

Mother's Name
SingleMarriedSeparatedDivorcedWidowedRe-marriedOther
YesNo

Home Address

Father's Name
SingleMarriedSeparatedDivorcedWidowedRe-marriedOther
YesNo

Home Address

Medical History

YesNo

YesNo

YesNo

YesNo
YesNo

YesNo

YesNo
YesNo
YesNo
YesNo
YesNo Rheumatic Fever
YesNo Heart Murmur
YesNo Heart Valve Disease
YesNo Heart Attack / Stroke
YesNo Prosthetic Joint / Valve
YesNo High/ Low Blood Pressure
YesNo Blood Disorder
YesNo Infectious Disease
YesNo HIV/ AIDS
YesNo Hepatitis
YesNo Kidney Disease
YesNo
YesNo Thyroid Disease
YesNo Liver Disease
YesNo Asthma
YesNo Tuberculosis (TB)
YesNo Cancer/ Radiation therapy
YesNo Diabetes
YesNo Stomach Ulcers
YesNo Eating disorder (e.g. Bulimia)
YesNo Herpes (any type)
YesNo Skin disease (e.g. Eczema)
YesNo Persistent Headaches / Migraines
YesNo
YesNo Never or Brain Disease
YesNo Seizures / Epilepsy
YesNo Autism
YesNo Arthritis
YesNo Bone Disorder
YesNo Fainting or Dizziness
YesNo Vision or Hearing Problems
YesNo Sleep Apnea
YesNo Sinus Problems
YesNo Allergies
YesNo Other

Dental History

YesNo

YesNo

YesNo


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

Insurance Information

Our office bills the Patient or Responsible Party directly for all services rendered. You will be provided with a Standard Information Form to submit to your carrier to determine the amount of orthodontic coverage to which you are entitled. We are also happy to answer any questions you might have regarding the insurance process and provide any assistance you might require.

YesNoDualUnsure YesNo

Take your smile to the next level!

We are here to help. Schedule a Consultation now!

Two convenient locations to serve you

LONDON OFFICE

218 Commissioner's Rd. W London, Ontario N6J 1Y1

(519) 685-3060

admin@marcycurranortho.com

ST. THOMAS OFFICE

291 Talbot Street St. Thomas, Ontario N5P 1B5

(519) 207-3061

info@marcyorthodontics.ca