Confidential Patient Information

*Last Name:
*First Name:
Nickname:
Email:
*Gender:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Home Phone:
School:
Grade:
Employed By:
Occupation:
Business Phone:
Whom may we thank for recommending us?
Name of Dentist:
Date of last visit:
Related Patients That Are Or Have Been Under Our Care:

Parent Information (please complete if patient is a minor)

Parent 1
First Name:
Middle Initial:
Last Name:
Address (if different from patient):
City:
ST:
Zip:
Home Phone:
Work Phone:
Email Address:
Employer:
Employer Address:
City:
ST:
Zip:
Parent 2
First Name:
Middle Initial:
Last Name:
Address (if different from patient):
City:
ST:
Zip:
Home Phone:
Work Phone:
Email Address:
Employer:
Employer Address:
City:
ST:
Zip:

Information About Person Responsible For This Account (if different from patient)

*First Name:
Middle Initial:
*Last Name:
Relationship to Patient:
Employer:
Occupation:
*Address:
*City:
*State:
*Zip:
*Main Phone:
Business Phone:
Email:
If divorce is involved, who is the custodial parent?
May patient information be released to the non-custodial parent?

Orthodontic Insurance Information

Primary Insured's Name:
Subscriber ID Or Soc Sec #:
Insurance Company Name:
Group No.:
Date Of Birth:
Insurance Co. Address:
Do you have dual orthodontic coverage?
2nd Insured's Name:
Subscriber ID Or Soc Sec #:
Insurance Company Name:
Group No.:
Date Of Birth:
Insurance Co. Address:

Emergency Information

Contact Person In Case Of Emergency:
Phone:
Relationship to Patient:

Medical History

Physician's Name:
Phone:
Address:
Is the patient currently experiencing health problems?
Explain:
Is the patient taking medications?
List:
Has the patient ever taken Bisphosphonates?
When?
For how long?
Is the patient allergic to any medications?
List:
Have the patient's tonsils or adenoids been removed?
Women: Is the patient pregnant?
Nursing?
Is the patient taking birth conrtol?
Please check if the patient has had any of the following conditions:
Is there any other condition or problem we should know about?

Information For Patients Under 18 Years Of Age

Has the patient ever had a finger sucking habit?
Has the patient reached puberty?
Girls: started menstruation?
When?
Boys: voice changed?
When?
Height:
Do you feel growth is completed?
Father's Height:
Mother's Height:
Adopted?

Dental History

Is there any unfinished dental care, i.e. crowns, fillings?
Dental Check-up Frequency:
Is the patient apprehensive about dental treatment?
Has the patient had previous orthodontic treatment?
With whom:
Have siblings or parents had orthodontic treatment?
Have there been any changes in the patient's bite or dental alignment?
What are your chief concerns related to your bite or the position of your teeth?
 Other:  
Please check if there is a history of:
Is there any other information that may be helpful?
I understand that the information I have given is correct to the best of my knowledge. It will be held in the strictest of confidence per HIPAA regulations. It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services. I understand that I am responsible for payment of services rendered and also responsible for any co-payment and deductibles that my insurance does not cover.