Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Marital Status:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Mother of patient:
if patient is under 18
Father of patient:
if patient is under 18
  Medical / Dental History     
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Asthma
  Heart Attack/Stroke
  Hypertension/High Blood Pressure
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  Cancer
  Growth Problems
  Diabetes
  Bone Disorders/Bone Loss
  Seizures/Epilepsy
  Treated for Emotional Problems
  Latex/Metal Allergy
  Allergies
If you answered yes to any of the above questions , please explain:
Dentist Name:
  Speech problems/therapy?
  Grind or clench teeth?
  Finger/Thumb habits?
  Injury to face/jaw?
  Mouth breathing?
  Missing or extra permanent teeth?
  Frequent headaches?
  Brush/Floss Teeth Daily?
  Lip/Nail Biting?
  Jaw Joint Noise?
  Requires premedication?
  Frequently chews gum?
  Snoring?
If you answered yes to any of the above questions, please explain:
What payment options would be best for you?

Have you had any additional consultations for braces?

I give my permission for the following:

What is your number one concern with your smile?
How excited are you about having braces?
Patient name:  
Signature of Patient or Responsible Party: Date:
I, , acknowledge that I have received and reviewed the Office Privacy Practice Notice for Holt Orthodontics.