Patient Biographical Information    
*Whom may we thank for referring you to our practice?     
 
*First Name:  
 Middle Initial:
*Last Name:  
 Nickname:
*Birthdate:    
*Gender:
*Age:  
*Address:  
*City:  
*State:  
*Zip:  
   
This form being completed by:  
Explain Other:
With whom does the patient reside?
Explain Other:
*Main Phone:  
*Cell Phone:  
*Email:  
   
   
School:
Grade:
 
Has patient begun puberty:
If patient is a girl, has menstruation begun:
Has the patient grown in the past year or has their shoe size changed recently:
What is the patients main orthodontic concern?
List any sports, hobbies, or musical instruments played:
Please list the name and age of any siblings:
Please list the names of any friends or family currently in the practice:
 
  Dental History     
 
*Dentist Name:  
*Has the patient had an orthodontic consult or treatment?
 
If so, when?
 
*Please answer the following questions. (Cannot be left blank.)
  Speech problems/therapy?
  Grind or clench teeth?
  Oral habits (thumb/finger sucking, nail biting)?
  Injury to face, jaw, teeth or mouth?
  Pain, tenderness or noise in either jaw?
  Mouth breathing?
  Snores during sleep?
  Requires premedication?
  Any missing or extra permanent teeth?
  Periodontal/gum treatment
  TMJ/Jaw Joint Treatment
 
Please provide necessary explanations below:
 
   Medical History     
 
Physician Name:
Date of last Physical:
Patient Health:
 
 
Any major illness, please explain:
Any Heart Problems:
Is patient currently under the care of a physician? Please explain:
Any Growth Disorders:
List any medications currently being taken by the patient:
Are you taking any bisphosphonates(i.e. Fosamax, Boniva, Zometa, etc) for bone loss:
List any drug allergies or sensitivities that the patient may have:
Ever been hospitalized::
   
  Responsible Party Information   
*First Name:  
 Middle Initial:
*Last Name:  
 Marital Status:
*Years at Current Address  
*Own or Rent  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Cell Phone:  
*Email:  
 *Employer:  
*Occupation:  
 Work Phone:
*Years at Employment  
 
  Dental Insurance Information   
 If you would like us to look into your insurance benefits, please provide the following insurance information
Name of Insurance Company:
Insurance Address:
Group Number:
Subscriber DOB:
Subscriber ID: