Patient Biographical Information    
*First Name:  
*Middle Initial:  
*Last Name:  
Prefers to be called:
*Birthdate:    
Age:
*Gender:  
*Physical Address:  
*City:  
*State:  
*Zip:  
*Home Phone:  
2nd/Cell Phone:
Work Phone:
Mailing Address:
City:
State:
Zip:
Has any immediate member of your family been a patient in our office?
Name/Relationship:
Whom may we thank for referring you to our practice?
List any hobbies, interests, or musical instruments played:
What is the patients main orthodontic concern?
Any special concerns about undergoing orthodontic treatment?
  Financial Party Information    
Who is financially responsible for this account?
Physical Address:  
*City:  
*State:  
*Zip:  
Relationship:
Mailing Address:
City:
State:
Zip:
*Main Phone:  
2nd/Cell Phone:
Work Phone #:
Email:
Employer:
Occupation:
# of years there?
Spouse:
Spouse Employer:
Spouse Occupation:
# of years there?
I grant permission for the following people to receive financial/treatment information on my or my child's account: (list names & relationship)
  Insurance Information    

Dental/Orthodontic insurance is a benefit purchased by/for you to help cover your treatment fees. We cannot be responsible for the type of policy that has been purchased. As a courtesy, we will complete and file a claim on your behalf; however you are responsible for the entire fee. If the information you supply is incomplete or inaccurate, you will be responsible for full payment to our office as well as filing claims to your insurance carrier.

Primary Policy
Dental Coverage:
Subscriber Name:
Subscriber Date of Birth:  
Subscriber Social Security Number:
Subscriber Insurance ID #:
Subscriber Group #:
Orthodontic Coverage:
Subscriber Employer:
Insurance Company:
Insurance Address:
Insurance Phone #:
Date insurance became effective:
Secondary Policy
Dental Coverage:
Subscriber Name:
Subscriber Date of Birth:  
Subscriber Social Security Number:
Subscriber Insurance ID #:
Subscriber Group #:
Orthodontic Coverage:
Subscriber Employer:
Insurance Company:
Insurance Address:
Insurance Phone #:
Date insurance became effective:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Location:
Has the patient had an orthodontic consultant or treatment?
If so, when?
 
Brush teeth daily?
 
Floss teeth daily?
Has the patient had any of the conditions listed below. Please select YES or NO. Do not leave blank.
  Speech problems/therapy?
  Grind or clench teeth?
  Oral habits (thumb/finger sucking, lip/nail biting)?
  Until what age?   
  Mouth breathing?
  Snores during sleep?
  Any missing or extra permanent teeth?
  Apprehensive about dental procedures?
  Frequently Chew Gum?
  Teeth sensitive to hot/cold?
  Frequent canker/cold sores?
  Biological parent had orthodontic treatment?
  Fluoride treatments?
  Injury to face, jaw, teeth or mouth?
  Discomfort from teeth or gums?
  Pain, tenderness or noise in either jaw?
  Frequent headaches?
  Neck/shoulder pain?
  Frequent sore throats?
  Difficulty chewing/swallowing food?
  Teeth throb/ache?
  Would the patient mind wearing braces?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Location:
Date of last Physical:  
Patient Health:
List any serious illnesses or medical problems:
Has the patient ever taken bisphophonate drugs (Fosamax, Boniva, Actonel)?
List any allergies (including latex, vinyl, metals, drugs/medications):
List any prescription and non-prescription drugs now being taken:
Has the patient had any of the conditions listed below. Please select YES or NO. Do not leave blank.
  Diabetes
  Pneumonia
  Heart Trouble
  Rheumatic Fever
  Tuberculosis
  Mononucleosis
  Mental Retardation
  Autism
  Arthritis
  Epilepsy
  Asthma
  Anemia
  Prolonged Bleeding
  Bone Disorders
  Pregnant?
  Frequent colds/flu
  Learning Disabilities
  ADD/ADHD
  Physical Disabilities
  HIV
  Ear Infections
  Emotional Problems
  Thyroid Problems
  Fainting/Dizzy Spells
  Adenoids Removed
  Tonsils Removed
  Hepatitis
  Growth Problems
   
Due Date:  
If any of the above medical questions were answered 'Yes' , please explain:
Does the patient have any congenital (born with) problems?
Has patient ever been diagnosed with a heart murmur?
Has a doctor/dentist recommended the patient take antibiotics for dental work?
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Father: Mother: Stepfather Stepmother
Name:
Address:
Home Phone:
Cell Phone:
Occupation:
Employer:
Do mother, father & child all live together?
If not, who does child live with? (name) Relationship:
Custodial Parent/Guardian
Physical Address: Mailing Address:
City: City:
State: State:
Zip: Zip:
Home Phone: Work Phone:
Cell Phone: E-mail Addresses:
School:
Other children in family: DOB:
1.    
2.    
3.    
4.    
Grade:
Sex Had ortho treatment?
Has patient begun puberty:
If patient is female, has menstruation begun:
If patient is male, has his voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Does the patient's facial appearance most resemble:
Are you aware that the success of orthodontic treatment depends upon cooperation?
Will the patient's cooperation be: