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: Self Mother Father Other Explain Other:	Responsible Party Marital Status: Single Married Divorced Widowed *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: Self Mother Father Other Explain Other:	Responsible Party Marital Status: Single Married Divorced Widowed 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?    NoYes      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? NoYes	NoYes 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?
NoYes Diabetes   NoYes Arthritis   NoYes Hepatitis   NoYes Tuberculosis   NoYes Asthma   NoYes Spectrum Disorder   NoYes Epilepsy   NoYes Kidney Disease	NoYes Prolonged Bleeding   NoYes Brain Injury   NoYes Heart Trouble   NoYes Rheumatic Fever   NoYes Tonsilitis   NoYes Anemia   NoYes Growth Problems Other:
Please explain any YES answers:

Dental History
Please select YES if there is a history of any of the following:
NoYes Jaw joint popping   NoYes Mouth breather   NoYes Missing teeth   NoYes Noise/pain in jaw or ears   NoYes Frequent headaches   NoYes Extra teeth	NoYes Uncomfortable bite   NoYes Injury to head/neck/jaw   NoYes Previously Treated TMJ   NoYes Clenching/grinding teeth   NoYes Sucked thumb/fingers Year stopped:
Please explain any YES answers:

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? NoYes Has patient had any previous orthodontic treatment or consultations? NoYes 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.