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Our Patients

Downtown Orthodontics sees patients of all ages – from children to adults. If you think you or your child could benefit from orthodontic treatment, it’s never too late to correct your bite. Contact us today for more information.

COVID-19 PANDEMIC DENTAL TREATMENT CONSENT FORM

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, all patients are required to review and submit a consent form prior to coming in for their next dental appointment.

Patient Name

First Name*

Last Name*

Email

I confirm that I am not presenting any of the core symptoms of COVID-19 as identified above.*

I confirm that, to my knowledge, I am not currently positive for COVID-19.*

I confirm that, to my knowledge, I have not come into contact with someone who has tested positive for COVID-19 in the past 14 days.*

I confirm I am not waiting for results of a COVID-19 test that was ordered in the past 14 days.*

Date:

covid

PATIENT HISTORY FORM

Please complete this form as a new patient to Downtown Orthodontics as requested by the office or doctor.

This form is being reviewed and submitted by:

Patient Name

Birth date

Name of Parent or Guardian (if applicable):

Mother

Father

PLEASE INDICATE PARENTS’ RELATIONSHIP STATUS:

Address

City

Postal Code

Telephone:

Home

Business (M)

(F)

Cell

Email Address (Optional)

Physician

Telephone

Dentist

Telephone

Dental Insurance Co. #1

Dental Insurance Co. #2

Subscriber:

D.O.B.:

Subscriber:

D.O.B.:

Policy/Group #:

I.D. #:

Policy/Group #:

I.D. #:

Medical History

1. DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH?

2. ARE YOU PRESENTLY UNDER THE CARE OF A PHYSICIAN?

3. ARE YOU PRESENTLY TAKING ANY MEDICINES OR DRUGS?

If Yes, please specify

4. HAVE YOU EVER BEEN HOSPITALIZED, OR HAD A SERIOUS ILLNESS?

6. DO YOU BRUISE EASILY?

8. DO YOU SUFFER FROM FREQUENT HEADACHES?

10. DO YOU HAVE FREQUENT SINUS TROUBLE OR NASAL CONGESTION?

5. DO YOU BLEED ABNORMALLY?

7. DO YOU HEAL EASILY AND NORMALLY?

9. DO YOU HAVE ANY EAR PROBLEMS?

11. DO YOU GET FREQUENT COLDS OR SORE THROATS?

12. FEMALES ONLY:

ARE YOU TAKING BIRTH CONTROL PILLS?

ARE YOU PREGNANT?

If yes, at what stage of pregnancy?

13. DO YOU HAVE ANY ALLERGIES?

IF YES, PLEASE SPECIFY:

other

14. A) HAVE YOU EVER HAD, OR BEEN TREATED FOR ANY OF THE FOLLOWING:

B) If you have any disease, problem, or condition not listed above, please specify:

Dental History

1. DO YOU CONSIDER YOURSELF TO BE IN GOOD DENTAL HEALTH?

2. ARE YOU NERVOUS ABOUT GOING TO THE DENTIST?

3. HAVE YOU EVER HAD A BAD DENTAL EXPERIENCE?

If so, please describe:

4. HAVE YOU EVER HAD AN INJURY TO YOUR FACE OR JAWS?

If so, please describe:

5. Date of last dental exam:

X-RAYS TAKEN?

6. Conditions currently being treated by your dentist:

7. How frequently do you brush your teeth?

8. How frequently do you floss your teeth?

9. What is your reason for seeking orthodontic treatment?

10. HAVE YOU RECEIVED ANY PAST ORTHODONTIC TREATMENT?

If yes, please describe:

11. WERE YOU REFERRED TO OUR OFFICE?

If yes, by whom?

If no, how did you hear about our office?

12. OFFICE USE ONLY Referral information

PAN/RADIOGRAPH

If yes, date of pan

date of return

Parental/Guardian Consent

I,

(parent or guardian) for

do hereby authorize Dr. Darren Tkach to perform an examination to determine the need for possible orthodontic treatment. As the patient is a minor, I hereby sign on his/her behalf as legal guardian. I authorize Dr. Darren Tkach to discuss aspects of the oral health of the aforementioned patient, or other relevant health information with other health care professionals I have seen (e.g. MD, DDS). I hereby confirm that, to the best of my knowledge, the above information is accurate and correct.

Parent or Guardian Signature

Relationship to Patient

Dr. Darren Tkach

Date

Children

Children who still have some baby teeth may require orthodontic treatment for the correction of specific problems. These problems may include the following:

  • Correction of a habit such as thumb sucking, which can move teeth and affect the bite
  • Early treatment to address severe developing crowding
  • The correction of tooth interferences like cross-bites, which may damage permanent teeth and affect bite development
  • The correction of growth-related problems in the upper or lower jaw

Teenagers

Most commonly, teenagers will wear braces to correct many types of problems. Often people will assume that the orthodontist simply straightens the teeth to improve the appearance of the patient’s smile. This is only part of the story. A corrected bite is also important to allow proper chewing, to minimize abnormal tooth wear, to ensure balanced jaw and muscle function, and to ensure the greatest ease when brushing and flossing the teeth.

Adults 

Adults can also benefit from the many advantages of orthodontic treatment. Even if some tooth wear or damage has occurred, adjusting the position and shape of teeth can restore their appearance and function. Orthodontic treatment can also make it easier to replace missing teeth with implants after the braces are gone.

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