patient biographical information
*First Name:
*Last Name:
Preferred Name:
*Birthdate:
*Gender:
*Marital Status:
*Social Security #:

*Address:
*City:
*State:
*Zip:
School:
Grade:
*Main Phone:
2nd/Cell Phone:
Email:
*Employed By/Occupation:
*Business Phone:  


Please list the names of any friends or family currently in the practice:


List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?
 
If other, how?  

Has the patient had an orthodontic consultation?
If so, when?


By whom?  
Have they had previous orthodontic treatment?
 
If so, when?
By whom?
Name of Dentist:  
Date of Last Visit:  


Parent Information (for patients under 18 only)
Mother/Guardian Information
*First Name:
Middle Initial:
*Last Name:
Social Security #:
Birthdate:
*Address:  
*City:
*State:
*Zip:


*Main Phone:
2nd/Cell Phone:
Email:
Employer:
Work Phone #:


Father/Guardian Information
First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Address:
City:
State:
Zip:


Main Phone:
2nd/Cell Phone:
Email:
Employer:
Work Phone #:


Dental Insurance Information
Primary Dental Insurance
Insured's Name:
Insurance Company:
Insured's DOB:
Insured's Social Security #:
Subscriber ID #:
Group No.:

Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Employer:
Relationship to Patient:


Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Insured's Name:
Insurance Company:
Insured's DOB
Insured's Social Security #:
Subscriber ID #:
Group No.:

Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Employer:
Relationship to Patient:


Patient Medical History
Physician Name:
Is patient currently under a physician's care?
City:
Reason if yes:
List any medications currently being taken by the patient:

Are you allergic to or have you had any reactions to the following?
Local Anesthetics (e.g. Novacaine)
Sulfa Drugs
Penicillin or Other Antibiotics
Any Metals (e.g. nickel, mercury, etc.)
Latex Rubber
Other (Please List Below)
List any other Allergens:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Tuberculosis/Lung Disease
  Hepatitis
  Tonsils/Adenoids Removed
  Nervous Disorders
  Bone Disorders/Bone Loss
  Handicaps/Disabilities
  Asthma
  Received Radiation Treatment
  Growth Problems
  Diabetes
  Seizures/Epilepsy
  Arthritis



If any of the above medical questions were answered 'Yes' , please explain:
Are there any other past or present medical or dental condition that we should know about?