Confidential Patient Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
School:
Grade:
*Address:
*City:
*State:
*Zip:
*Main Phone:
Alternate/Cell Phone:
Email:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does patient live with?   
Please list the names and birthdates of siblings:
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:  
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:  
*Address:
*City:
*State:
*Zip:
Social Security #:
Employer:
Occupation:
Work Phone #:
 
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:
 Length of Employment:
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Primary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber's SSN:
Subscriber ID #:
Group No.:
Subscriber's Birthdate:
Do you have dual dental coverage?  
  Emergency Information    
Name of nearest relative not living with you:
Phone:
Relationship to Patient:
Dentist Information
Dentist Name:
Check-up Frequency:   
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?