ABOUT YOU    
Email:
*Last Name:  
*First Name:  
Middle Initial:
Title:
I prefer to be called:
*Gender:
*Birthdate:    
Age:
Social Security #:
*Address:  
*City:  
*State:  
*Zip:  
Marital Status:
Hm #:  
Pager/Other #:
Wk #:   Ext: 
DL #:
Employer:
Employer's Address:
How long there?
Occupation:
Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:    
Dentist Name:
Last Visit Date:  
  SPOUSE INFORMATION   
His/Her Name:
Employer:
Wk #:   Ext: 
SS #:
Birthdate:  
Person Responsile for Account:
Wk #:   Ext: 
Hm #:
Billing Address:
Relation:
SS #:
Employer:
DL #:
  ORTHODONTIC INSURANCE   
Primary
Orthodontic Coverage:
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Group# (Plan, Local, or Policy #):
Dental Coverage:
Insured's Name:
Relation:
Insured's Birthdate:  
Insured's ID #:
Employer:
Secondary
Orthodontic Coverage:
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Group# (Plan, Local, or Policy #):
Dental Coverage:
Insured's Name:
Relation:
Insured's Birthdate:  
Insured's ID #:
Employer:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Wk #:
Hm #:
   Medical History     
Do you have a personal physician?
Your current physical health is:
Are you currently under the care of a physician?
Please explain:
Are you taking any prescription/over-the-counter-drugs?
Please list each one:
For Women:
Are you pregnant?
Week #:
Are you nursing?
Have you ever had any of the following diseases or medical problems?
  Abnormal Bleeding
  Anemia
  Artificial/Joints/Valves
  Asthma/Arthritis
  Blood Transfusion
  Cancer/Chemotherapy
  Congenital Heart Defect
  Diabetes
  Difficulty Breathing
  Drug/Alcohol Abuse
  Emphysema
  Epilepsy/Seizures/Fainting
  Fever Blisters/Herpes
  Glaucoma
  Heart Attack/Stroke
  Heart Murmur
  Heart Surgery/Pacemaker
  Hemophilia
  Hepatitis
  High/Low Blood Pressure
  HIV+/AIDS
  Hospitalized for Any Reason
  Kidney Problems
  Mitral Valve Prolapse
  Psychiatric Problems
  Radiation Treatment
  Rheumatic/Scarlet Fever
  Severe/Frequent Headaches
  Shingles
  Sickle Cell Disease/Traits
  Sinus Problems
  Tuberculosis (TB)
  Ulcers/Colitis
  Venereal Disease
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
  Aspirin
  Any Metal/Plastics
  Codeine
  Dental Anesthetics
  Erythromycin
  Latex
  Penicillin
  Tetracycline
  Other
Please list any other drugs/materials that you are allergic to:
  Dental History     
What are the main concerns that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Gums ever bleed?
Have you ever had an injury to your:        
Do you have any speech problems?
   Do you generally breathe through your mouth?
If yes, please circle:      
   Do you have any missing or extra permanent teeth?
   Have you ever taken Phen-Fen?
If yes, when?
   Do you smoke or use tobacco in any form?
  Acknowledgements    
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. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature:
Date:  
Thank you for filling out this form completely.
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 the office, use the services of one or more credit reporting services.
Signature:                                                Date:                     
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance.
Signature:                                                Date: