Confidential Patient Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
*Address:
*City:
*State:
*Zip:
Employer/School:  
*Home Phone:
Cell Phone:
Email:
Social Security #:
Work/School Phone:  
If patient is a minor, please answer the following
Father's Name: Mother's Name:
Address: Address:
City: City:
State: State:
Zip: Zip:
Home Phone Home Phone:
Cell Phone: Cell Phone:
E-mail: E-mail:
Marital Status: Marital Status:
Employer: Employer:
Work Phone: Work Phone:
Who does patient live with?    Please specify:  
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
How did you hear about our practice?   Please specify:   
  Emergency Information    
Name of nearest relative not living with you:
Address:
City
State:
Zip:
Phone:
Relationship to Patient:
  Confidential Financial Party Information    
 
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
Marital Status:
How long at this address?
*Main Phone:
Cell Phone:
Email:
*Birthdate:  
Relationship to Patient:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Spouse's First Name:
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:  
Length of Employment:
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Primary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:  
Policy Holder's Employer:  
Relationship to Patient:
 
  Dental History     
Dentist Name:
Is all dental work completed?    
Last Dental Visit:  
Has the patient had an orthodontic consult or treatment?
If so, when?
By whom?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
 Speech problems/therapy
 Clench or grind teeth
Oral habits (thumb/finger sucking, lip/nail biting)
 Injury to face, jaw, teeth or mouth
 Discomfort from teeth or gums
 Pain, tenderness or noise in either jaw
 Frequent headaches
 Neck/shoulder pain
 Chipped or injured permanent teeth
 Previous root canal therapy
 Bad taste/mouth odor
 Abnormal swallowing (tongue thrust)
 Mouth breathing
 Snores during sleep
 Apprehensive about dental care
 Jaw fractures, cysts, mouth infections
 Frequent canker sores or cold sores
 Problems with food trapped between teeth
 Previous periodontal (gum) treatment
 Teeth sensitive to hot or cold
 Clicking/popping/pain in TMJ(jaw joint)
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
   Has there been any change in the patient's general health within the last year?
   Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
   Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescirption):
      FEMALES: Are you pregnant
Allergies or drug reaction to:
 Latex
 Nickel
 Medications
If yes to any allergies, please explain in detail or list anything not mentioned above.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
 Heart Murmur
 Heart Disease
 Angina
 Liver Disease / Jaundice / Hepatitis
 Kidney Disease
 Heart Attack/Stroke
 Hemophilia
 Hypertension/High Blood Pressure
 Prolonged Bleeding/Transfusion
 Anemia / Blood disorder
 HIV/AIDS
 Tonsils/Adenoids Removed
 Handicaps/Disabilities
 Diabetes
 Growth Problems
 Tuberculosis or Lung Disease
 Cancer
 ADD/ADHD
 Radiation Treatment
 Hormone Therapy
 Seizures / Epilepsy / Neurological Disease
 Treated for Emotional Problems
 Asthma
 Respiratory problems / Emphysema
 Persistent swollen neck glands
 Low blood pressure
 Persistent cough
If any of the above medical questions were answered 'Yes' , please explain:
 Does the patient need to premedicate prior to dental visit?  
If yes, please explain.