Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Cell Phone:
* 2nd Phone:
* Email:
Social Security #:

Orthodontic concerns:
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:
* Birthdate:
Relationship to Patient:
* Email:
* Address:
* City:
* State:
* Zip:
* Cell Phone:
2nd Phone:
Work Phone #:
Employer:
Occupation:
Social Security #:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Cell Phone:
2nd Phone:
Work Phone #:
Employer:
Occupation:
Social Security #:

Dental Insurance Information

Primary Policy Holder's Name:
Relationship to Patient:
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:

Secondary Policy Holder's Name:
Relationship to Patient:
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?

Please select YES if the patient has had any of the conditions listed below either now or in the past.
* Speech problems/therapy?
* Clench or Grind 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)?
* Requires Premedication?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

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

List any medications currently being taken by the patient:
List any drug allergies or sensitivities the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
* Arthritis
* Asthma
* Bone Disorders/Bone Loss
* Cancer
* Congenital Heart Defect
* Endocrine Problems
* Ever Been Hospitalized
* Growth Problems
* Handicaps/Disabilities
* Heart Attack/Stroke
* Heart Disease
* Heart Murmur
* Hemophilia
* Hepatitis
* HIV/AIDS
* Hormone Therapy
* Hypertension/High Blood Pressure
* Latex/Metal Allergy
* Liver Disease
* Nervous Disorders
* Prolonged Bleeding/Transfusion
* Received Radiation Treatment
* Rheumatic Fever
* Seizures/Epilepsy
* Treated for Emotional Problems
* Tuberculosis/Lung Disease
If any of the above medical questions were answered 'Yes' , please explain: