Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
Age:
* Gender:
* Address:
* City:
* State:
* Zip:
Village/Subdivision:
* Email:
* Primary Phone:
Secondary Phone:
Name of school:
Grade:
Special interests, sports, or hobbies:
Patient's Dentist:
Phone #:
Please list any other family members we have treated:

Whom can we thank for this referral?
Dentist:
Friends:
Friends:
Friends:
Other:

Name of person accompanying child today:
Relationship:

Siblings

Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:
Name:
Birthdate:
Gender:

Mother Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (if different)
City:
State:
* Zip:
Marital Status:
Social Security #:
Primary Phone:
Secondary Phone:
Email:
Employer:

Father Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (if different)
City:
State:
* Zip:
Marital Status:
Social Security #:
Primary Phone:
Secondary Phone:
Email:
Employer:

Person Responsible for Account

Who is responsible for account:
* First Name:
Middle Initial:
* Last Name:
Birthdate:
* Address:
* City:
* State:
* Zip:
* Primary Phone:
Cell:
Work:
Email:
Social Security #:
Employer:

Primary Dental Insurance Information

Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
ID# or SS#:

Secondary Dental Insurance Information

Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
ID# or SS#:

Medical History

Please select YES if the patient has had any of the conditions listed below either now or in the past.
* Heart Murmur/Congenital Defect
* Diabetes
* Rheumatic Fever
* Cancer
* HIV/AIDS
* Hemophilia
* Blood Transfusions
* Asthma
* Hepatitis
* Tuberculosis
* Heart Problems
* Sinus Problems
* Hypertension/High Blood Pressure
* Convulsions/Epilepsy
* Abdominal Bleeding
* Hearing Impairment
* Operations/Stays in a Hospital
* Kidney/Liver Problems
* Handicaps/Disabilities
* Allergies to Drugs, Metals, or Foods
* Antibiotics Prior to Dental Treatment
* Other Medical Problems
* Bisphosphonate Medications - ie. Fosomax, etc.
* Currently Pregnant
If any of the above medical questions were answered 'Yes' , please explain:

Dental History

Please select YES if the patient has had any of the conditions listed below either now or in the past.
* Injuries to Face/Teeth
* Other Orthodontic Treatment
* Pain/Noises in the Jaw Joint (TMJ)
* Root Resorption
* Periodontal Disease
* Unfavorable Dental Experience
* Missing Teeth
* Extra Teeth
* Finger Sucking
* Tongue Thrusting
* Speech Problems
* Mouth Breathing
* Gums Bleed
* Grind Teeth
If any of the above dental questions were answered 'Yes', please explain:
What do you see as the main problem with your teeth?

Emergency Information

Who should we contact in the event of an emergency?
Phone:
Relationship to Patient:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.