Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Nickname:
*Gender:
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Secondary Phone:
Email:
Would you like to receive text/email reminders?
Please list the names of any friends or family currently in the practice:
How did you hear about our office?




 
Please list all immediate family members and their birthdates:
First Name:
Last Name:
Birthdate:
First Name:
Last Name:
Birthdate:
First Name:
Last Name:
Birthdate:
First Name:
Last Name:
Birthdate:

Financial Party Information

*First Name:
Middle Initial:
*Last Name:
Social Security #
Relationship to Patient:
Email:
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Secondary Phone:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Policy Holder:
Policy Holder's D.O.B.
ID/SSN #:
Group #:
Employer:

Dental History

General Dentist Practice Name:
Check-up Frequency:
Last Dental Visit:
 
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?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Neck/shoulder pain?
Frequent sore throats?
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?
Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

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
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
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:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Please note that if patient needs pre-medication before procedures that our office needs written documentation from the patients physician beforehand. If the patient has a heart murmur or other complication but does not require pre-medication we need written documentation from the patient's physician stating this as well. Please call the office at (877) SMILE-10 with any questions, thank you.