Patient Biographical Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Gender:   Male Female *Marital Status: Single Married Divorced Widowed
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.
NoYes Asthma   NoYes Heart Attack/Stroke   NoYes Hypertension/High Blood Pressure   NoYes HIV/AIDS   NoYes Hepatitis   NoYes Tonsils/Adenoids Removed   NoYes Cancer	NoYes Growth Problems   NoYes Diabetes   NoYes Bone Disorders/Bone Loss   NoYes Seizures/Epilepsy   NoYes Treated for Emotional Problems   NoYes Latex/Metal Allergy   NoYes Allergies
If you answered yes to any of the above questions , please explain:
Dentist Name:   NoYes Speech problems/therapy?   NoYes Grind or clench teeth?   NoYes Finger/Thumb habits?   NoYes Injury to face/jaw?   NoYes Mouth breathing?   NoYes Missing or extra permanent teeth?	NoYes Frequent headaches?   NoYes Brush/Floss Teeth Daily?   NoYes Lip/Nail Biting?   NoYes Jaw Joint Noise?   NoYes Requires premedication?   NoYes Frequently chews gum?   NoYes Snoring?
If you answered yes to any of the above questions, please explain:

What payment options would be best for you? Payment in full with discount In-house financing

Have you had any additional consultations for braces? Yes No

I give my permission for the following: To take x-rays, photos Post first name along with photos on Facebook for contests/before and after photos

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.