Patient Information

*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Email:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell/Other Phone:
Work Phone: (if applicable)
Marital Status: (if applicable)
DL: (if applicable)
Employer: (if applicable)
Occupation: (if applicable)
How long there? (if applicable)
Whom may we thank for referring you to our practice?
Dentist Name:
Last Visit Date:
Dentist's Phone Number:
Relative or friend not living with you (in case of emergency):
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Other family members seen by us:

Parents name seeking treatment / Person responsible for Account

*First Name:
Middle Initial:
*Last Name:
Employer:
Work Phone:
Social Security #:
Spouse Name:

Primary Insurance

Policy Holder's Name:
Relationship to Patient:
Policy Holder's DOB:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:
Do you have dual dental coverage?

(If yes, complete information below)

Secondary Insurance

Policy Holder's Name:
Relationship to Patient:
Policy Holder's DOB:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:
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. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payable to me.

Medical History

Does patient have a personal physician?
Physician Name:
Date of last Physical:
Phone:
Patient Health:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Do you smoke/vape or use tobacco?
Have you had any metal rods, pins or implants?
List any medications currently being taken by the patient (include non-prescription):

Have you ever taken Fosamax or any other bisphosphonate?
Has puberty begun?
FEMALES: Has menstruation begun?
Please select YES or No for the Following Questions - Do Not Leave Blank
Abnormal Bleeding
High Blood Pressure
Arthritis
Liver Disease
Blood Transfusion
Mitral Valve Prolapse
Diabetes
Radiation Treatment
Seizures
Fainting Spells
Sinus Problems
Thyroid Problems
Heart Attack/Surgery
Hepatitis
Herpes/Fever Blisters
Alcohol/Drug Abuse
Kidney Problems
Asthma
Lupus
Colitis
Psychiatric Problems
Emphysema
Stroke
Frequent Headaches
Hay Fever
Ulcers
Venereal Disease
AIDS
Anemia
Artificial Bones/Joints/Valves
Low Blood Pressure
Cancer/Chemotherapy
Pacemaker
Congenital Heart Defect
Rheumatic/Scarlet Fever
Shingles
Sickle Cell Disease/Traits
Autism/Aspergers
Tuberculosis
Heart Murmur
Hospitalized for any reason
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following:
Aspirin
Penicillin or other antibiotics
Codeine
Jewelry/Metals
Dental anesthetics
Latex
Plastics
Nuts
Other:
Please list any other drugs/materials that you are allergic to:
What are the main goals that you would like orthodontics to accomplish?
Have you ever had any orthodontic treatment?
Have you ever had a serious/difficult problem associated with Dental work?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ? TMD?)
Your current dental health is:
Are you missing any permanent teeth including wisdom teeth?
Have you ever had an injury to your:
Do you have any speech problems?
Do you generally breathe through your mouth?
If yes, when?
Do you grind your teeth either during the day or night?
Do you have any oral habits (i.e. thumb sucking)?
If yes, please explain: