Welcome and thank you for referring your friends and family to our office!!

In order to help us accurately diagnose and treat you, PLEASE FULLY COMPLETE THIS FORM

Our Practice began more than 50 years ago and we have always provided treatment for our patients that we would recommend for our own family. We pride ourselves on our multiple doctor, cooperative approach for all of our patients. 

PATIENT INFORMATION: 

How did you hear about us?

Do you have orthodontic insurance?

PARENT INFORMATION IF APPLICABLE:

MOTHER'S INFORMATION:

FATHER'S INFORMATION:

PATIENT'S DENTAL & MEDICAL HISTORY:

Any outstanding dental work to be done?
Have you ever had any orthodontic consultation?
Have you ever had any previous orthodontic treatment?
Does the patient have any history of the following
Is the patient healthy?
Blood Pressure Problems
Allergies
Taking any Medications
Past Medical Problems
Any Medications need before Dental Visit
Past Hospitalizations
Use of puffer/inhaler
Bleeding problems
Past or future Operations
Any past or present Heart problems
Pregnant
Asthma

Your Signature

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Please Support the Drs. Eckler, Black & Leung's Sick Kids Fund at the Hospital for Sick Children by clicking on the icon below:

SMILE SOLUTIONS, DR. BLACK, DR ECKLER, DR LEUNG, ORTHODONTIST, BRAMPTON, MISSISSAUGA, INVISALIGN, BRACES, INVISIBLE, CLEAR
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