*First Name:
 MI:
*Last Name:
 Age:
*Date of Birth:
 Preferred Name:
Gender:
Is the patient adopted?
Phone:
*Home Address:
Patient's School/Employer
Grade/Position:
General Dentist:
How did you hear about our office?
Has Dr. Davies treated another member of your family?
If yes, please name:
Have you visited another orthodontist before?
If yes, for what reason?

What are the main concerns you would like Dr. Davies to address?
Person Filling Out Form:
Relationship to patient:

*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Date of Birth:
*Address:
*City:
*State:
*Zip:
Email:
*Phone:
2nd Phone:
Work Phone:
Employer:
Occupation:

If this responsible party is the subscriber for the DENTAL insurance, please fill out the following information.
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Date of Birth:
*Address:
*City:
*State:
*Zip:
Email:
*Phone:
2nd Phone:
Work Phone #:
Employer:
Occupation:

If this responsible party is the subscriber for the DENTAL insurance, please fill out the following information.
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:
Patient's Physician:
Currently under the care of a physician?
If yes, for what reason?
Does the patient require premedication/antibiotics before dental treatment?
If yes, please explain:
Currently taking medication? (include non-prescription)
If yes, please list:
Any sensitivities or allergies to the following?
Please select Y (yes) or N (no) for the following questions. Your answers are for our records only and will be considered confidential. CANNOT BE BLANK

Is the patient in excellent health?
Damaged or artificial heart valves
Is the patient's height/weight normal for his/her age?
Heart murmur or rheumatic heart disease
Respiratory problems or Sinus trouble
Birth defects
Thyroid or endocrine problems
Diabetes
Persistent swollen neck glands
Fainting spells or seizures
Frequent colds or sore throats
Radiation or chemotherapy
Stomach ulcer or hyperacidity
Mental health problems or nervous disorder
Tonsils or adenoids removed? At what age?
Epilepsy or other neurological disease
Hepatitis, jaundice, or liver disease
Frequent headaches
Abnormal bleeding or Anemia
Tumor (cancerous or benign)
Arthritis, joint problems, or artificial joints/limbs
Currently pregnant
Cardiovascular disease or high blood pressure
If there is a condition that was not named, please explain:
Have you been informed of any missing or extra permanent teeth?
If yes, where?
Has the patient ever had pain/tenderness in the jaw joint (TMJ/TMD)?
If yes, please explain?
Have there been any injuries to the patient's face, mouth or chin?
If yes, please explain?

Does/did the patient have any of the following habits?
CBCT (Cone Beam Computer Assembled Tomography) offers our patients enhanced diagnostic value at a significantly reduced exposure. CBCT scans can image the entire head and most of the neck. As orthodontists, we evaluate teeth, jaws and surrounding bone using CBCT’s for those limited purposes. Our training and dental license does not provide for evaluating and diagnosing outside those areas. However, since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The cost is $100.00 which may not be covered by your insurance. Please indicate your preference below.


I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform Dr. Davies of any changes in the patient’s medical status.

I hereby authorize release of any information related to insurance claims. I consent to examination by Dr. Davies and I authorize payment of insurance benefits.

By typing my name below, I acknowledge that I am signing this form and that I have received and agree to Davies Orthodontics Notice of Privacy Practices.