Orthodontic Patient Information
Confidential Patient Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone #:
*First Name:
Middle Initial:
*Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have additional dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Oral habits (thumb/finger sucking)?
No
Yes
Difficulty Chewing/Swallowing?
No
Yes
Mouth breathing?
No
Yes
Requires antibiotic premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Tuberculosis/Lung Disease
No
Yes
Liver Disease/Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Disease/Rheumatic Fever
No
Yes
Heart Murmur
No
Yes
Hemophilia or Other Blood Disease
No
Yes
High or Low Blood Pressure
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Cancer
No
Yes
Growth Problems
No
Yes
Endocrine Problems
No
Yes
Latex/Metal Allergy
No
Yes
Bone/Joint Disease
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Handicaps/Disabilities
No
Yes
Asthma
No
Yes
Arthritis
No
Yes
Mental Health Treatment
No
Yes
Ever Been Hospitalized
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
I hereby authorize insurance payment for orthodontic services rendered to be sent directly to Dental Health Orthodontics. I authorize the release of any dental or medical information necessary to process insurance claims. I understand that, where appropriate, credit bureau reports may be obtained. Any amount not covered by insurance will remain the full responsibility of the Guarantor.