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?
No
Yes
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?
No
Yes
No
Yes
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?
No
Yes
Diabetes
No
Yes
Arthritis
No
Yes
Hepatitis
No
Yes
Tuberculosis
No
Yes
Asthma
No
Yes
Spectrum Disorder
No
Yes
Epilepsy
No
Yes
Kidney Disease
No
Yes
Prolonged Bleeding
No
Yes
Brain Injury
No
Yes
Heart Trouble
No
Yes
Rheumatic Fever
No
Yes
Tonsilitis
No
Yes
Anemia
No
Yes
Growth Problems
Other:
Please explain any
YES
answers:
Dental History
Please select YES if there is a history of any of the following:
No
Yes
Jaw joint popping
No
Yes
Mouth breather
No
Yes
Missing teeth
No
Yes
Noise/pain in jaw or ears
No
Yes
Frequent headaches
No
Yes
Extra teeth
No
Yes
Uncomfortable bite
No
Yes
Injury to head/neck/jaw
No
Yes
Previously Treated TMJ
No
Yes
Clenching/grinding teeth
No
Yes
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?
No
Yes
Has patient had any previous orthodontic treatment or consultations?
No
Yes
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.