Welcome to our office! To aid us in better commuication, please fill out this form as completely as possible.
Name of Person Completing Form: Relationship to Patient:
  Patient Info    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*DOB:    
Age:
*Gender:
*Address:  
*City:  
*State:  
*Zip:  
*Home #:  
Cell #:
General Dentist:
Last Dental Visit:  
Whom may we thank for referring you?
Other Family members seen by us:
  Parent/Responsible Party #1   
 
First Name:  
Middle Initial:
Last Name:  
Relationship to Patient:
Address:  
City:  
State:  
Zip:  
Home #:
Cell #:
Email:
Work #:
Spouse Name:
Relationship to Patient:
Work #:
Cell #:
  Parent/Responsible Party #2 (if applicable)   
 
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Address:
City:
State:
Zip:
Home #:
Cell #:
Email:
Work #:
Spouse Name:
Relationship to Patient:
Work #:
Cell #:
  Primary Dental Insurance   
Insurance Company:
Policy ID:
Group #:
Insurance Address
Insurance Phone:
Policy Holder's DOB:
Policy Holder's name:
SS #:
Employer:
Relationship to Patient:
If other, explain:
  Secondary Dental Insurance   
Insurance Company:
Policy ID:
Group #:
Insurance Address
Insurance Phone:
Policy Holder's DOB:
Policy Holder's name:
SS #:
Employer:
Relationship to Patient:
If other, explain:
  General Information   
 What is the patient's main orthodontic concern?
General Information (if patient is child)
 School:
 Hobbies
 Brothers/Sisters (include ages)
   Medical History     
Medical Physician:
Phone:
Last Visit:  
If yes, explain:
Medication:
Is patient allergic to any of the following? (Check all that apply)
Other Allergies/Sensitivities:
Check all that apply
Explain:
  Dental History     
Explain:   
Dental History (Check all that apply)
   
Describe:  
Describe:  
Which teeth?  
Where:  
Describe:  
Describe:  
If so, Explain:
Additional comments regarding medical or dental health:
I hereby acknowledge that I have reviewed a copy of this Privacy Notice. I hereby certify that I have reviewed the above history and that it is accurate to my knowledge at this time. If there are future changes in this information, I will inform this practice of these changes immediately. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office.
Signature:    Date: