Submit Your Patient Information and Health History Form Online to Parker Orthodontics!
Please take a minute to complete your registration and health history information online! Complete this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will have your information downloaded and ready when you arrive for your first appointment.
This website is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All of your personal health information is confidential, and will not be shared with anyone, aside from those involved in your treatment, without your consent.
  Confidential Patient Information    
*First Name:
Middle Initial:
*Last Name:
*Birthdate:  
*Gender:
Nickname:
*Address:
*City:
*State:
*Zip:
*Best Phone:
2nd/Cell Phone:
Email:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does patient live with?   
Please list the names of any friends or family currently in the practice:
School: Grade:
List any sports, hobbies, or musical instruments played:
General Dentist Name:
Whom may we thank for referring you to our practice?
  Confidential Financial Party Information    
 
*First Name:
*Last Name:
Marital Status:  
*Best Phone:
2nd/Cell Phone:
*Email:  
*Birthdate:  
Relationship to Patient:
*Address:
*City:
*State:
*Zip:
Social Security #:
Employer:
Occupation:
Work Phone #:
 
*Spouse or Other Parent's First Name:
*Last Name:
Marital Status:  
*Best Phone:
2nd/Cell Phone:
*Email:
*Birthdate:  
Relationship to Patient:
*Address:
*City:
*State:
*Zip:
Social Security #:
Employer:
Occupation:
Work Phone #:
 
  Emergency Information    
Name of nearest relative not living with you:
Phone:
Relationship to Patient:
  Dental Insurance Information    
Primary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
   Medical History     
Patient Health: 
   Has there been any change in the patient's general health within the last year?
If so, what changed?  
     Do you take any medications for osteoporosis such as Fosamax, Boniva or Actonel?
Allergies or drug reaction to:
Latex Penicillin or other antibiotics
Sulfa drugs Aspirin, Ibuprofen, Tylenol
Local anesthetics Codeine or other narcotics  
Peanuts/Nuts Metal/Nickel Allergy
List any other allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Hepatitis
Prolonged/Abnormal Bleeding
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Thyroid / Endocrine Problems
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Persistent swollen neck glands
Chronic Ear Aches
Do you experience soreness in the muscles of your face or around your ears?
FEMALES: Are you pregnant
Has the patient grown in the past year or has their shoe size changed recently
If any of the above medical questions were answered 'Yes' , please explain:
Is there any condition affecting the patient's health other than those mentioned? If yes, please list:
  Dental History     
Dentist Name:  Check-up Frequency:  
            Is all dental work completed at this time?
            Does the Patient need to premedicate prior to dental visit?
            Has the patient had an orthodontic consult or treatment?
If so, when?   
Has either biological parent ever had orthodontic treatment?   
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?
Grind or clench teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Snores during sleep?
Mouth breathing, difficulty breathing?
Any missing or extra permanent teeth?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Problems with food trapped between teeth?
Do you notice clicking or popping in your jaw joint?
Do you have a history of jaw joint problems?
Strong gag reflex?
If any of the above dental questions were answered 'Yes', please explain:
  Would the patient be willing to wear braces if necessary to correct the problem?
  Are you interested in Invisalign?
Is there any reason why treatment should not start immediately?