Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
*Gender:  
*Marital Status:  
*Birthdate:  
*Address:  
*City:  
*State:  
*Zip:  
*Patient Phone:  
Work Phone:
Patient Cell:
Email:
(We confirm appointments using e-mail and text message. Please leave blank if you prefer to be contacted by phone.)
Dentist:
Physician:
  Financial Party Information    
IF PATIENT IS A MINOR, PLEASE PROVIDE RESPONSIBILE PARTY INFORMATION:
Mother:
Address:
City:
State:
Zip:
Account Access:
Mother Phone:
Work Phone:
Mother's Cell:
Email:
Father:
Address:
City:
State:
Zip:
Account Access:
Father Phone:
Work Phone:
Father's Cell:
Email:
  Patient Health History     
Your careful and complete answers to the following questions will be helpful in the preparation of an orthodontic program for you or your child. Only by knowing the many factors which can influence a problem is it possible for the orthodontist to recommend the most suitable and beneficial therapy.
What is the patient's main orthodontic concern?
Any History of:
  Arthritis
  Auto immune diseases
  Diabetes
  HIV/AIDS
  High or Low Blood Pressure
  Liver problems/hepatitis
  Injury or tooth extraction
  Hepatitis
  Blood Disease
  TMJ/Jaw abnormalities
  Asthma, allergies, hay fever
Bone/joint disease  
Epilepsy/convulsions  
Heart Disease, rheumatic fever  
Kidney trouble  
X-ray exposure, extensive  
Gingivitis/Gum disease  
Cancer  
Missing/extracted teeth  
Prolonged bleeding following an extraction?  
Other illnesses  
Have you ever taken Bisphosphates? i.e. (Fosamax, Boniva, etc...)
If yes, please comment:
REMINDER: Women who are pregnant, or think they may be pregnant, must notify the assistant to avoid x-rays
  Food Allergies
  Major Operations
  Tonsils/Adenoids Removed
  Good general health
  Thumb/finger habit
  Previous orthodontic tx
  Other Concerns
Injury to face/mouth/teeth  
Women-Pregnant
Difficulty chewing/swallowing  
Difficulty breathing through nose  
Puberty-Reached  
Boys-Voice Changed?
Girls-Menstruation started?
If yes, please comment:
Current medications being taken:
Do you have Orthodontic Insurance?   If yes, complete the following
 Orthodontic Insurance 
Primary Orthodontic Insurance
Policy Holder: Group #
Policy Holder's DOB: Subscriber #:
Relationship to patient: Insurance Company
Employer: Insurance Co. Phone #:
    Insurance Co. Address
Do you have dual coverage? Group #:
Policy Holder: Subscriber #:
Policy Holder's DOB: Insurance Company
Relationship to patient: Insurance Co. Phone #:
Employer: Insurance Co. Address
  By providing your insurance information, you agree that we may share any information requested by your insurance provider for the purposes of your claim. You also authorize us to invoice your insurance and be paid directly by them.  

Person completing this form:
Relationship to patient: