*First Name:
MI:
*Last Name:
Name preferred to be called:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Cell Phone:
*Email:
 
Social Security #:

If patient is a minor, give parent's or guardian's name:
*Who does the patient live with?
What school does the patient attend?
*First Name:
Middle Initial:
*Last Name:
*Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*How long at this address?
Previous Address (less than 3 years)
*Email:
*Cell Phone #:
Work Phone #:
Social Security #:
*Employer:
*Occupation:
*Length of Employment:

If applicable, complete for Spouse/Other parent
First Name:
Middle Initial:
Last Name:
Address:
City:
*State:
*Zip:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Cell Phone #:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
City:
State:
Zip:
Policy Holder's Cell #:
Policy Holder's Birthdate:
Insurance Company:
Insurance State:
Insurance Co. Phone No.:
Subscriber ID #:
Group #:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's Address:
City:
State:
Zip:
Policy Holder's Cell #:
Policy Holder's Birthdate:
Insurance Company:
Insurance State:
Insurance Co. Phone No.:
Subscriber ID #:
Group #:
Emergency Contact:
Phone:
Dentist Name:
Last Dental Visit:
*Does the Patient need antibiotic premedication for medical conditions prior to dental visit?
What is the patient's main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Frequent headaches?
Jaw pain/tenderness?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Mouth breathing?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Penicillin, Sulfa or other antibiotics
Metal Allergy
Aspirin, Ibuprofen, Tylenol, Codeine or other narcotics
Please give more detail to any "Yes" answered questions from above and list any other allergies:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Condition: murmur, damage, valves, defects or disease
Heart Attack/Stroke/Cardiovascular disease
High or Low Blood Pressure
Blood disorder or bleeding disorders (hemophilia, anemia, prolonged bleeding)
HIV/AIDS
Tonsils/Adenoids Removed or Large Tonsils
Handicaps/Disabilities
Arthritis / Joint problems
Prosthetic joints
Bone Disorders/Bone Loss
Currently taking or have taken Bisphosphonates (Fosamax, Boniva)
Sinus trouble
Diabetes
Cancer
Received Radiation Treatment
Thyroid / Endocrine / Growth Problems
Hormone Therapy
Nervous / Emotional Problems or Disorders
Seizures / Epilepsy / Neurological Disease
Asthma
Respiratory problems / Emphysema / Tuberculosis - Lung Disease
Persistent swollen neck glands
Sexually transmitted disease
FEMALES: Are you pregnant
If any of the above medical questions were answered 'Yes' , please explain:
  *I hereby acknowledge that I have read and received the HIPAA policies of Orthodontic Associates.

Release of Information

THIS RELEASE OF INFORMATION WILL REMAIN IN EFFECT UNTIL TERMINATED BY ME IN WRITING AND SUBMITTED TO THE PRIVACY OFFICER AT oa@oasmiles.com

Messages and/or communications from our office

*If unable to reach me: you may leave a detailed message.
 
*Who is filling the Health History in relation to the patient?
*Relationship to patient: