*First Name:
 
Middle Initial:
*Last Name:
 
I prefer to be called:
*Birthdate:
 
Age:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Telephone:
 
*2nd/Cell phone:
 
*Email:
 

Marital Status:
 
Employed by:
Occupation:

Spouse's Name:
Employed by:
Occupation:
Address:
City:
Zip:

Dentist:
City:
Telephone:
Physician:
City:
Telephone:
General Health:
Presently under medical care for:
Birth Defects:
Do you take any medication to treat Osteoporosis or other bone disorder including bisphosphonates such as Fosamax, Boniva, and Zometa, Prolia, and similar medications?
Medication currently being taken (drug and dose):
Allergies:
Latex Allergies
 
Do you need to premedicate for dental appointments due to heart disorder/murmur?
 

Please select YES or NO to the following and date:
Adenoids (Removed)
 
Year:
Heart disorder/murmur
 
Year:
Arthritis
 
Year:
Hepatitis
 
Year:
Blood/bleeding problems
 
Year:
HIV
 
Year:
Bone Disorder
 
Year:
Hospitalized
 
Year:
Diabetes
 
Year:
Lung disorder
 
Year:
Ear/nose Infections
 
Year:
Rheumatic Fever
 
Year:
Emotional
 
Year:
Scoliosis
 
Year:
Endocrine
 
Year:
Speech difficulty
 
Year:
Epilepsy
 
Year:
Tonsils (removed)
 
Year:
Fainting spells
 
Year:
STD
 
Year:
Glaucoma
 
Year:
Asthma
 
Year:
Please give any additional information or details necessary
Date of last dental check-up:
Brushing teeth:
Injury or trauma to the face or teeth:
Oral Habits (lip biting, nail biting, etc.): Specify:
Airway/Sleep Habits:
Bruxism (grinds teeth):
Jaw joint (TMJ):
Speech:
Difficulty in pronounciation:
Speech Lessons
Describe major reason for seeking orthodontic treatment:
How did you become aware of the orthodontic problem?
Other family members with similar dental conditions:
Other family members with orthodontic treatment:
Have you had any experience with another orthodontist?
Dr.
How and when did you first hear about our office?
Whom may we thank for referring you to our office?
Any additional comments:
Responsible Party Legal First Name:
Responsible Party Legal Last Name:
Responsible Party Address (If different from patient):
Phone:
Email:

Do you have orthodontic insurance?
If yes, insurance will be verified prior to your appointment with the following information:
Name of Insurance Company:
Subscriber ID#:
Subscriber Name:
Employer's Name:
Subscriber Birthdate:
Group #:
Subscriber Social Security#:
Subscriber Phone:
Subscriber Email:
If dual orthodontic insurance, please fill out the following information:
Name of Insurance Company:
Subscriber ID#:
Subscriber Name:
Employer's Name:
Subscriber Birthdate:
Group #:
Subscriber Social Security #:
Subscriber Phone:
Subscriber Email:
Please bring all of your insurance information to your first appointment.
HIPAA Notice of Privacy Practices
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. Records made in the process of examinations, treatment, and retention may be used for purposes of consultations with other professionals, research, education, or publication in journals. In addition, we are required to safeguard patient information sent via email by using encrypted coding. This is to ensure the information within the message is read by the intended recipient only. If you would like to receive emails unencrypted, you have the right to request a change. Please be advised that by doing so may result in email interception by an unauthorized third party. All patient specific, treatment information emailed to your dentist or other dental professional will still be sent encrypted. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
 
Questionnaire completed by:
Relation to patient: