Patient Information

* First Name:
* Last Name:
* Gender:
Social Security #:
* DOB:
* Home Address:
* City:
* State:
* Zip:
* Cell Phone:
Home Phone:
* Email:
* Are you an existing patient?
Please select location you would like to visit?

Whom may we thank for referring you?

* What type of treatment are you most interested in?

Medical History

Are you taking any medication?
Do you have any allergies?
Are you allergic to latex or nickel
Major illness:
Operations:
Accidents:
Abnormal Bleeding/Hemophilia
Anemia
Asthma/Hayfever
Bone Disorders
Congenital Heart Defect
Diabetes
Epilepsy
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/AIDS
Nervous Disorders
Radiation/Chemotherapy
Tuberculosis
Cancer
Pregnant
Other Conditions

Dental History

Have you ever had an orthodontic consultation or treatment before?
If yes, when and where:
Do you have a general dentist?
Name of your dentist?
Phone number of your dentist:
Date of last dental visit:
Presently in dental pain
Injury to face, jaw, teeth, or mouth
Bleeding gums
Oral habits
Mouth breathing
Discomfort from teeth or gums
Pain, tenderness, or noise in either jaw
Grind or clench teeth
Speech problems/therapy
Snores during sleep
Frequent headaches
Floss daily
Frequently chews gum
Requires premedication

Responsible Party Information (if patient is a minor)

Father's Information:

First Name:
Last Name:
DOB:
SSN:
Home Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:

Mother's Information:

First Name:
Last Name:
DOB:
SSN:
Home Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:

Insurance Information

Dental Insurance Company Name:
Subscriber's Name:
Subscriber's ID/SS#:
Subscriber's D.O.B.:
Employer:
Relationship to patient:

Any Alternative (secondary) Insurance Company:
Subscriber's Name:
Subscriber's ID/SS#:
Subscriber's D.O.B.:
Employer:
Relationship to patient: