Confidential Patient Information

*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
School:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Responsible Party Information

*First Name:
Middle Initial:
*Last Name:
*Birthdate:
 
Relationship to Patient:
Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
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?
  (If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
 
Height of mother?
Height of father?
Has the patient had an orthodontic consult or treatment?
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?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Ever experienced any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Is any part of the patient's mouth sensitive to temperature?
Is any part of the patient's mouth sensitive to pressure?
Pain, tenderness or noise in either jaw?
Oral habits (thumb/finger sucking, lip/nail biting)?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Is the patient sensitive or self-conscious about his/her teeth?
Are you aware that some appointments will be during school/work hours?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
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
Liver Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Herpes
Tonsils/Adenoids Removed
Cancer
Received Radiation Treatment
Growth Problems
Hormone Therapy
Latex/Metal Allergy
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Treated for Emotional Problems
Is the patient pregnant
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:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

Acknowledgement of Receipt of Notice of Privacy Practices

**You may refuse to Sign This Acknowledgement**

Omaha Orthodontics will assume the parent that brings the patient to our office is the custodial parent and we will release information regarding treatment progress to that parent at the appointment.

If another relative/adult brings the child to the appointment, we will assume that the custodial parent has given permission for that person to receive updates on treatment progress while the child is in our office.

Please authorize the release of Parent information to the following people by phone or in the child’s absence.

I have received a copy of Omaha Orthodontics Notice of Privacy Practices on behalf of: