Confidential Patient Information

* First Name:
MI:
* 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?

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:

* Spouse or Other Parent's First Name:
Middle Initial:
* Last Name:
Social Security #:
Birthdate:
* Relationship to Patient:
Employer:
Occupation:
Length of Employment:
* Main 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:
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. Cannot be blank.
* Speech problems/therapy?
* Clench or Grind Teeth?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Neck/shoulder pain?
* Frequent sore throats?
* Chipped or injured permanent teeth?
* Teeth sensitive to hot or cold?
* Previous root canal therapy?
* Bad taste/mouth odor?
* Previous periodontal (gum) treatment?
* Abnormal swallowing (tongue thrust)?
* Teeth that irritate tongue, cheek, lip, etc?
* Numerous fillings?
* Brush teeth daily?
* Floss teeth daily?
* Fluoride treatments?
* Mouth breathing?
* Snores during sleep?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
* Thumb or finger habit as a child?
* Jaw Fractures, cysts, mouth infections?
* Bleeding gums?
* Other periodontal (gum) problems?
* Frequent canker sores or cold sores?
* Have wisdom teeth been removed?
* Problems with food trapped between teeth?
* Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
* Do you experience soreness in the muscles of your face or around your ears?
* Have you had a TMJ screening?
* Do you have a history of jaw joint problems?
* Have you been treated for "TMJ"?
* Do you notice clicking or popping in your jaw joint?
* Do you clench your teeth?
* Has your jaw ever locked?
* Do you have difficulty chewing or opening your mouth?
* Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

* Physician Name:
Date of Last Physical:
Patient Health:
* Physician Phone Number:

* Has there been any change in the patient's general health within the last year?
* Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
* Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
* Latex
* Penicillin or other antibiotics
* Sulfa drugs
* Aspirin, Ibuprofen, Tylenol
* Local anesthetics
* Codeine or other narcotics
* Other:
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.
* Heart Murmur
* Damaged or artificial heart valves
* Congenital Heart Defect
* Heart Disease
* Rheumatic Fever
* Angina
* Liver Disease / Jaundice / Hepatitis
* Kidney Disease
* Heart Attack/Stroke
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia / Blood disorder
* HIV/AIDS
* Tonsils/Adenoids Removed
* Handicaps/Disabilities
* Arthritis / Joint problems
* Large Tonsils
* Sinus trouble
* Substance abuse problem (past or present)
* Bone fractures/trauma to face/jaw
* Prosthetic joints
* Diabetes
* Growth Problems
* Tuberculosis or Lung Disease
* Pneumonia
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Thyroid / Endocrine Problems
* Hormone Therapy
* Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Seizures / Epilepsy / Neurological Disease
* Treated for Emotional Problems
* Asthma
* Respiratory problems / Emphysema
* Persistent swollen neck glands
* Sexually transmitted disease
* Low blood pressure
* Persistent cough
FEMALES: Are you pregnant
* Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.) Teeth - If your teeth could be changed, how would you like them to change?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
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:

Assignment of Benefits for Insurance Payments (if applicable)

I hereby authorize payment of group insurance benefits directly to this office. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

I understand that I am responsible for payment of services rendered and also responsible for paying any insurance co-payment and deductibles that my insurance does not cover. I hereby authorize the orthodontist to release all information necessary to secure the payment or benefits.

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the orthodontic staff to perform the necessary orthodontic service the patient may need.

I understand that I will not be charged for any services without my consent. By clicking Submit, you agree to these terms and conditions.

Notice of Privacy Rights

By typing your name in the box below, you agree you have read and/or received a copy of our office's Notice of Privacy Practice.