Patient Information    
*First Name:  
Middle Initial:
*Last Name:  
*Telephone:  
*Birthdate:    
*Address:  
*City:  
*State:  
*Zip:  
Dentist:  
Hobbies & Interests:
Referred by:
Patient likes to be called:
If a student, School and Grade:
  1st Responsible Party Information    
*First Name:  
Middle Initial:
*Last Name:  
Relationship to Patient:
Explain Other:
Responsible Party Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*Home Telephone:  
Work Telephone:
Cell Telephone:
Email:
Employer:
Occupation:
Insurance
Dental Insurance Carrier:
Subscriber Name:
SSN or ID Number:
Subscriber Birthdate:
Group #:
  2nd Responsible Party Information (If Applicable)*    
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Explain Other:
Responsible Party Marital Status:
Address:
City:
State:
Zip:
Home Telephone:
Work Telephone:
Cell Telephone:
Email:
Employer:
Occupation:
Insurance
Dental Insurance Carrier:
Subscriber Name:
SSN or ID Number:
Subscriber Birthdate:
Group #:
*If there are 2 responsible parties (in different households):
Is custody shared?         If YES, at what percentage?     
With whom does the patient primarily reside?     
Is there a court order regarding Insurance?         
   Medical History     
Is patient in good health?
Has he/she been treated by a physician in the last 2 years?
Is he/she taking any medications now?
List any allergies:
Has the patient ever had any of the following?
  Diabetes
  Arthritis
  Hepatitis
  Tuberculosis
  Asthma
  Nervous Disorders
  Epilepsy
  Kidney Disease
  Prolonged Bleeding
  Brain Injury
  Heart Trouble
  Rheumatic Fever
  Tonsilitis
  Anemia
  Growth Problems
Other:
  Dental History     
Please select YES if there is a history of any of the following:
  Jaw joint popping
  Mouth breather
  Missing teeth
  Noise/pain in jaw or ears
  Frequent headaches
  Extra teeth
  Uncomfortable bite
  Injury to head/neck/jaw
  Previously Treated TMJ
  Clenching/grinding teeth
  Sucked thumb/fingers
Year stopped:
If patient is a child, list the names and ages of any brothers and sisters:
Have others in the family had a similar condition or received ortodontic treatment?
Has patient had any previous orthodontic treatment or consultations?
When did patient last visit the Dentist?  
Any specific problem you would like us to fix?
 
I,     (person filling out form) attest that the above information is true and accurate and anuthorize (if applicable) Dr. Oshetski's office to bill insurance for treatment. I also acknowledge that I have recieved a copy of the office's Notice of Privacy Practices.