Patient Biographical Information    
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:  
Gender:
School Name:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
In order to keep your treatment on track, we will be sending you a confirmation email prior to each appointment. You may also receive a reminder via text messages or phone call. Which do you prefer?
Do you prefer general correspondence from our office by e-mail or hard copy (letter)? 
*We will only use your email address for appointment reminders and important communication with the office. We promise not to fill your inbox with spam
How did you hear about our office? (Please check all that apply)
Which search engine?
Name
Name
Other
  Responsible Party    
Primary Responsible Party
Relationship:
Marital Status:
Name:
SS#:
Email:
Employer:
No. of Years Employed:
Address (if different from patient)
   
   
   
   
   
Date of Birth:  
Cell Phone:
Occupation:
Work Phone:
Street:
City: State: Zip:
How long at residence: Home Phone:
Secondary Responsible Party, If Available
Relationship:
Marital Status:
Name:
SS#:
Email:
Employer:
No. of Years Employed:
Address (if different from patient)
   
   
   
   
Date of Birth:  
Cell Phone:
Occupation:
Work Phone:
Street:
City: State: Zip:
How long at residence: Home Phone:
  Dental Insurance Information  
Primary Insurance
Insured's Name: Insured's SS#:
Insurance Company: Group Number:
Insurance Company Address:   
Insured's Birthdate:   Insured's Employer:
Secondary Insurance
Insured's Name: Insured's SS#:
Insurance Company: Group Number:
Insurance Company Address:   
Insured's Birthdate:   Insured's Employer:
Emergency Information
Emergency contact not living with patient:
Phone Number: Relationship:
   Medical History     
Physician Name:
Phone Number:
Date of last Physical:  
Patient Health:
List any medications currently being taken by the patient:
List any allergies or sensitivities that the patient may have:
Does the patient require antibiotic pre-medication (prophylaxis) prior to any dental procedures?
Has the patient ever been hospitalized?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  ADD/ADHD
  Artificial Heart Valve
  AIDS/HIV+
  Anemia
  Angina
  Arthritis
  Asthma/Hay Fever
  Bleeding Disorders
  Bone Disorders
  Cancer
  Chemo/Rad Therapy
  Congenital Heart Disease
  Cosmetic Surgery
  Diabetes
  Disabilities/Handicaps
  Dizziness/Fainting
  Emotional Disorders
  Epilepsy/Seizures
  Growth /Hormonal Disorders
  Heart Attack
Females Only
  Has menstruation begun (This is useful in monitoring/modifying growth of head & jaw bones)
   
  Heart Murmur
  Heart Problems
  Hepatitis/Liver Disorder
  Herpes
  High Blood Pressure
  Joint Replacement
  Kidney Disease
  Latex/Metal Allergy
  Low Blood Pressure
  Nervous Disorders
  Pacemaker
  Pneumonia/Lung Disease
  Psychiatric Care
  Rheumatic Fever
  Sinus Trouble
  Sleep Apnea
  Stroke
  Tobacco Use
  Tuberculosis
 
  Pregnant
If any of the above medical questions were answered 'Yes' , please explain:
Do you have any medical condition(s) not listed above?
Are there any medical conditions that you would like to discuss with the Doctor in Private?
   
  Dental History     
General Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultation or treatment?
If so, when?  
What is the patient's main orthodontic concern?
Please select YES if any of the following apply to the patient either now or in the past.
  Speech problems/therapy
  Grind or clench teeth
  Injury to face, jaw, teeth or mouth
  Discomfort or pain from teeth or gums
  Pain or tenderness in either jaw
  Clicking or popping in either jaw
  Diagnosis of or treatment for TMD
  Tongue Thrust
  Frequently Chew Gum
  Nail Biting
  Thumb or Finger Sucking Habits
  Gums Bleed When Brushing
  Mouth breathing
  Snores during sleep
  Gum (periodontal) treatment
  Any missing or extra permanent teeth
  Apprehensive about dental care
  Smoke
If any of the above dental questions were answered 'Yes', please explain:
How do you feel about receiving orthodontic treatment?
Has anyone else in your family received orthodontic treatment? If so, how did they feel about the result?

1.    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 this office, use the services of one or more credit reporting services.  I certify that all information provided is accurate and understand that the information will be relied upon for granting credit and providing orthodontic services.  I hereby authorize this office to release all information necessary to obtain information on credit. 

2.    I understand that I am financially responsible for payment of services rendered and also responsible for charges not covered by or paid by my insurance for whatever reason.  I authorize payment directly to the orthodontic office of any group insurance benefits otherwise payable to me.  I understand that I am financially responsible for any charges not covered by this authorization.  I hereby authorize this office to release all information necessary to secure payment or benefits. 

3.         I have read and understand all questions above.  I certify that I have the information I have provided is correct and accurate to the best of my knowledge.  I will not hold this orthodontic office, the orthodontist or any member of the staff responsible for any errors or omissions that I have made in the completion of this form.  If there are any changes to the patient’s medical or dental history, it will be my responsibility to inform this practice. 

By clicking Submit below, I agree to all of the terms and conditions listed above.  

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