*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Home Phone:

If patient is a minor, give parent's or guardian's name:

List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

*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)
Do you rent or own your home?
Email:
*Cell Phone:
Social Security #:
Work Phone #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Cell Phone:
Work Phone #:
Employer:
Occupation:
Length of Employment:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Birthdate:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Insured's Birthdate:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?

Please select if the patient has had any of the conditions listed below either now or in the past. Check all that apply.
If any of the above dental questions were selected, please explain:
Do you have a history of jaw joint problems?
Do you notice clicking or popping in your jaw joint?
If any of the above TMJ questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction:
Please check all that apply if the patient has had any of the conditions listed below either now or in the past.
If any of the above medical questions were selected , please explain: