*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Primary Phone:
Secondary 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:

*Whom may we thank for referring you to our practice?
 

Main reason for seeking orthodontic treatment:
*First Name:
Middle Initial:
*Last Name:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (if less than 3 years)
Email:
*Primary Phone:
Secondary Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Primary Phone:
Secondary Phone:
Work Phone #:
Employer:
Occupation:
Length of Employment:
Policyholder's Name:
Relationship to Patient:
Policyholder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone #:
Policyholder's Social Security #:
Do you have dual dental coverage?
  (If yes, complete information below)

Policyholder's Name:
Relationship to Patient:
Policyholder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone #:
Policyholder's Social Security #:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Physician Name:
Date of Last Physical:
Phone:
Address:
City:
State:
Zip:

List:
List:
List:
List:
List:
Comment:
Comment:

Please check any of the following that you have had or currently have
Are there any medical conditions we have not discussed that you feel we should be aware of?
Does your physician recommend premedicating with antibiotics prior to dental procedures?
General Dentist:
Date of Last Visit:
Are you happy with the appearance of your teeth?

Please check any of the following which apply to you, and add any relevant comments
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
If yes, who and when?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?
How did they feel about the result?
Comment:
Comment:
Comment:
Comment:
Comment:
If the patient is under age 16, height of parents?
Are there any familial medical conditions we should know about?
What would you like to see in your orthodontist?
School/Grade Level:
Favorite Hobby:
Favorite Food:
Favorite Animal:
Favorite Person:
Favorite Sport:
Favorite Musical Artist:
Musical Instruments Played:
Siblings:
Any other information you would like us to know:
Comment:
Comment:
I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will so inform this practice. By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.