Patient Biographical Information

First Name:
Last Name:
Nickname:
Birthdate:
Gender:
Marital Status:
Social Security #:
Address:
City:
State:
Zip:
School:
Grade:
Main Phone:
Cell Phone:
Email:
Employer:
Work Phone:

What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice? If other, how?
Has the patient had an orthodontic consult?
If so, when? By whom?
Has the patient had an orthodontic treatment?
If so, when? By whom?
Dentist Name:
Last Dental Cleaning:

Parent Information

Mother/Guardian Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
Birthdate:
Employer:
Work Phone:

Father/Guardian Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
Birthdate:
Employer:
Work Phone:

Orthodontic Insurance Information

*Please skip this section if you do not have orthodontic insurance.
Primary Dental Insurance
Insured's Name:
Insurance Company Name:
Birthdate:
Social Security Number:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Insured's Employer:
Relationship to Patient:

Do you have dual dental coverage?
(If yes, complete information below)
Secondary Dental Insurance
Insured's Name:
Insurance Company Name:
Birthdate:
Social Security Number:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Insured's Employer:
Relationship to Patient:

Patient Medical History

Physician Name:
City:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex Rubber?
Local anesthetics (e.g. Novacaine)?
Any Metal (e.g. nickel, mercury, etc.)?
Penicillin or other antibiotics?
Sulfa drugs?
Other (Please list below)?
Please list any other drug allergies or sensitivities 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.
Arthritis or joint problems?
Asthma?
Bone disorders or loss?
Diabetes?
Growth problems?
Handicaps or disabilities?
Hepatitis?
Nervous disorders?
Radiation treatment?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions were answered 'Yes' , please explain:
Are there any other past or present medical or dental conditions that we should know about?

Informed Consent

Orthodontic Treatment in the Era of COVID-19


Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?