Lo Elliott Orthodontics

PRACTICE INFORMATION

*Practice Name

*Referring Dentist / Staff

*Practice Email

PATIENT INFORMATION

*Is patient a child or an adult?

Child
Adult

*Patient Legal First and Last Name

*Legal Sex

Female
Male

Add gender information (optional)

Our entire team is committed to making sure every patient feels safe, welcome and respected.

*Patient Birthdate

Patient Mailing Address

*Patient Contact Information

Home Phone
Cell Phone
Email Address

*Parent/Guardian Information

First and Last name

Relationship

Home Phone

Cell Phone

Additional Parent/Guardian Information

First and Last name

Relationship

Home Phone

Cell Phone

Insurance Information (Check all that apply)

MCFD - 077030 - PHN (10 digits)
FNHA - 40000 - Status Number
Cleft Palate/Syndrome - PHN (10 digits)
Dental Insurance

*Specific Areas of Concern

*Date of most recent examination/cleaning

*Is there pending dental work?

Yes
No
Uncertain

Planned Treatment/Date of Appointment &/or Additional Details

*Oral Hygiene Grade:

Additional Notes (if needed)

DOCUMENT UPLOAD

Please upload the following documents for the patients:

Routing/Patient Information Slip

Browse

Dated Panographic X-ray

Browse

Date PAN was taken:

Perio-Charting for Adults

Browse

newpatient@perfectsmile.ca | 250.562.2113 | www.perfectsmile.ca

Lo Elliott Orthodontics

PRACTICE INFORMATION

*Practice Name

*Referring Dentist / Staff

*Practice Email

PATIENT INFORMATION

*Is patient a child or an adult?

*Patient Legal First and Last Name

*Legal Sex

Add Gender information

*Patient Birthdate

Patient Mailing Address

*Patient Contact Information

*Parent/Guardian Information

Additional Parent/Guardian Information

Insurance Information (Check all that apply)

*Specific Areas of Concern

*Date of most recent examination/cleaning

*Is there pending dental work?

*Oral Hygiene Grade:

Additional Notes (if needed)

DOCUMENT UPLOAD

Routing/Patient Information Slip

Dated Panographic X-ray

Date PAN was taken:

Perio-Charting for Adults