Child Medical Information Form

Please complete this form. When you are finished, please click on the SEND button and your form will be submitted to us. Thank you.

If you have any questions, please contact our office at 780-435-3641. If you prefer you can fax the form to us at 780-436-4354 or bring in a printed copy with you to your appointment.

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your orthodontic care. All information will be kept confidential.

Patient Information

Parent's Information

Please note: Our office charges the patient directly for all professional services rendered. However, we will be happy to assist you with your dental claim form.

Insurance Information

Please remember that we are unable to accept assignment from your insurance carrier.

Please remember that we are unable to accept assignment from your insurance carrier.

Medical History

Growth Information for Patients Under 16 Years of Age

Dental History