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.
No
Yes
Asthma
No
Yes
Heart Attack/Stroke
No
Yes
Hypertension/High Blood Pressure
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
Tonsils/Adenoids Removed
No
Yes
Cancer
No
Yes
Growth Problems
No
Yes
Diabetes
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures/Epilepsy
No
Yes
Treated for Emotional Problems
No
Yes
Latex/Metal Allergy
No
Yes
Allergies
If you answered yes to any of the above questions , please explain:
Dentist Name:
No
Yes
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Finger/Thumb habits?
No
Yes
Injury to face/jaw?
No
Yes
Mouth breathing?
No
Yes
Missing or extra permanent teeth?
No
Yes
Frequent headaches?
No
Yes
Brush/Floss Teeth Daily?
No
Yes
Lip/Nail Biting?
No
Yes
Jaw Joint Noise?
No
Yes
Requires premedication?
No
Yes
Frequently chews gum?
No
Yes
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
.