Patient Biographical Information    
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:  
Gender:
Other Siblings:
School:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Whom may we thank for referring you to our practice?
  Responsible Party    
Primary Responsible Party
Relationship:
Marital Status:
Name:
SS#:
Email:
Employer:
No. of Years Employed:
Address (if different from patient)
   
   
   
   
Custodial Parent?
Date of Birth:  
Cell Phone:
Occupation:
Work Phone:
Street:
City: State: Zip:
How long at residence: Home Phone:
Secondary Responsible Party
Relationship:
Marital Status:
Name:
SS#:
Email:
Employer:
No. of Years Employed:
Address (if different from patient)
   
   
   
Custodial Parent?
Date of Birth:  
Cell Phone:
Occupation:
Work Phone:
Street:
City: State: Zip:
How long at residence: Home Phone:
Do you prefer correspondence from our office by e-mail or a hard copy (letter)?
  Dental Insurance Information  
Primary Insurance
Insured's Name: Insured's SS#:
Insurance Company: Group Number:
Insurance Company Address:
Insured's Birthdate:   Insured's Employer:
Secondary Insurance
Insured's Name: Insured's SS#:
Insurance Company: Group Number:
Insurance Company Address:
Insured's Birthdate:   Insured's Employer:
Emergency Information
Emergency contact not living with patient:
Phone Number: Relationship:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultation or treatment?
If so, when?  
What is the patient's main orthodontic concern?
Please select YES if the patient has any of the conditions listed below.
  Speech problems/therapy
  Grind or clench teeth
  Injury to face, jaw, teeth or mouth
  Discomfort from teeth or gums
  Pain, tenderness or noise in either jaw
  Frequent headaches
  Neck/shoulder pain
  Tongue Thrust
  Frequently Chew Gum
  Nail Biting
  Thumb or Finger Sucking Habits
  Gums Bleed When Brushing
  Mouth breathing
  Snores during sleep
  Requires premedication
  Any missing or extra permanent teeth
  Apprehensive about dental care
  Smoke
If any of the above dental questions were answered 'Yes', please explain:
How do you feel about receiving orthodontic treatment?
Has anyone else in your family received orthodontic treatment? If so, how did they feel about the result?
 
According to the following scale choose the appropriate number value to represent how likely you are to fall asleep during the day in the following situations. Try to be as honest as possible. If possible have your significant other help you fill this out.
0-never    1-slight chance    2-moderate    3-always
Sitting and reading
Watching T.V.
Sitting inactive in public (movie theater, meeting)
Sitting and talking to someone
Sitting quietly after lunch
As a passenger in a car for an hour without a break
Driving a vehicle for two or more hours (Skip if < 16 years old)
Lying down to rest in the afternoon when circumstances permit
   Medical History     
Physician Name:
Phone Number:
Date of last Physical:  
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Rheumatic Fever
  Tuberculosis/Lung Disease
  Pneumonia
  Liver Disease
  Kidney Disease
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  Sleep Apnea
  Sleep Disorder
Females Only
Has menstruation begun
Pregnant
  ADD/ADHD
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Handicaps/Disabilities
  Asthma
  Arthritis
  Treated for Emotional Problems
  Ever Been Hospitalized
  Gastroinstestinal Disorder
  Involved in a Serious Accident
If any of the above medical questions were answered 'Yes' , please explain:
Are there any medical conditions that you would like to discuss with the Doctor in Private?
   

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. I understand that I am responsible for payment of services rendered and also responsible for paying any insurance co-payment and deductibles that my insurances does not cover. I hereby authorize the orthodontist to release all information necessary to secure the payment or benefits.
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the orthodontic staff to perform the necessary orthodontic service the patient may need. I understand that I will not be charged for any services without my consent.
By clicking Submit, you agree to these terms and conditions.