Existing Orthodontic Patient Information

The following information is required by West Grande Prairie Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Person Responsible for Payment

Info of person responsible for payment of account (if different from above)

Dental History

Orthodontic History

Please rank the importance of the following:


Do you have any of the following issues with your jaw joint?

If so, how frequently/how painful?

I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.

We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time. Please sign that you have read and understand our policy.