Patient Information
Patient's First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Male
Female
Contact Cell Phone:
Parent/Guardian EMail
(If patient is a minor):
Social Security #:
Address:
Apt #:
City:
State:
Zip:
Describe main concerns about your teeth/smile:
Responsible Party Information
Who is the responsible party?
Mother
Father
Both
Myself (If over 18)
Other
Responsible Party First Name:
Last Name:
Contact Cell Phone:
Responsible Party First Name:
Last Name:
Contact Cell Phone:
Family Smile Information
What type of treatment are you interested in?
Orthodontic Evaluation
Metal Braces
Clear Braces
Invisalign
Other
How did you hear about our office?
Google/Internet
Insurance Company
Friend/Family
My Dentist
Website
Invisalign Website
Other
Any relatives/family members who have been to our office?
Yes
No
If yes, please list:
Dental Insurance Information
Do you have dental insurance?
Yes
No
Primary
Insurance Company Name:
Policy Holder's Name:
Policy Holder's ID:
Policy Holder's DOB:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Do you have secondary dental coverage?
Yes
No
(If yes, complete information below)
Secondary
Insurance Company Name:
Policy Holder's Name:
Policy Holder's ID:
Policy Holder's DOB:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Patient Dental History
Has the patient had an orthodontic exam or treatment?
Yes
No
Do you have a general dentist?
Yes
No
Dentist Name:
Dentist Phone:
Any speech problems?
Yes
No
Oral habits (thumb or finger sucking, lip or nail biting)?
Yes
No
Excessive bleeding gums?
Yes
No
Previous periodontal (gum) treatment?
Yes
No
Mouth breathing?
Yes
No
Snores during sleep?
Yes
No
Nervous about dental care?
Yes
No
Frequent canker sores or cold sores?
Yes
No
Injury to face, jaw, teeth, or mouth?
Yes
No
Does the Patient need to premedicate prior to dental visit?
Yes
No
Please describe any dental concerns and/or conditions we should know about:
Patient Medical History
Is the patient taking any medications?
Yes
No
If yes, please list:
Is the patient allergic to latex or nickel?
Yes
No
List any medication Allergies:
Please list any surgeries and/or major illnesses:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Attention Deficit Disorder (ADD/ADHD)
Yes
No
Autism Spectrum
Yes
No
Abnormal Bleeding/Hemophilia
Yes
No
Anemia or Blood Disorder
Yes
No
Asthma/Hayfever
Yes
No
Bone Disorders
Yes
No
Cancer
Yes
No
Congenital Heart Defect
Yes
No
Developmental Delay
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Genetic Disorders
Yes
No
Growth Problems
Yes
No
Heart Problems
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
HIV/AIDS
Yes
No
Intellectual Disability
Yes
No
Pregnant
Yes
No
Radiation/Chemotherapy
Yes
No
Tuberculosis
Yes
No
Any Other Conditions?
Orthodontic Family Information
List all children in your household under age 16.
Child's First Name:
Had Orthodontic Treatment?
Yes
No
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Child's First Name:
Had Orthodontic Treatment?
Yes
No
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Child's First Name:
Had Orthodontic Treatment?
Yes
No
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Child's First Name:
Had Orthodontic Treatment?
Yes
No
Age:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
I hereby acknowledge that I have been given the right to review the office's Notice of Privacy Practices. (HIPAA) A copy of this notice can be viewed
here.
I affirm that the information provided in these forms will be true and correct to the best of my knowledge. I certify that I understand the importance of a truthful health history and that my doctor and his/her staff will rely on the information provided for treating me. I will not hold my doctor, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may make in the completion of these forms.
In lieu of signature, Type Patient's Name (If Over 18) or Parent/Guardian (If Under 18):
Date: