Confidential Biographical Information

*First Name
Middle Initial
*Last Name
Nickname
*Birthdate
*Gender
*Address
*City
*State
*Zip
*Main Phone
2nd/Cell Phone
Email
Social Security #
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
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?

Confidential Financial Party Information

*First Name
Middle Initial
*Last Name
Marital Status
Relationship to Patient
*Birthdate
*Address
*City
*State
*Zip
How long at this address?
Previous Address (less than 3 years)
Email
*Main Phone
2nd/Cell Phone
Work Phone #
Social Security #
Employer
Occupation
Length of Employment
*First Name
Middle Initial
*Last Name
Social Security #
*Birthdate
Relationship to Patient
Employer
Occupation
Length of Employment
Work Phone #

Dental Insurance Information

Primary Dental Insurance
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 so, please name the Insurance Company below:
Secondary Dental Insurance
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.

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
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
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 (include non-prescription):

List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
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:
Height
Weight
School
Grade
Please list the name and birthdate of any siblings:
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:
Has either biological parent ever had orthodontic treatment:
 
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.