Patient Information
Whom may we thank for referring you to our office?
Any family members/friends treated in our office? If yes, please list:
Yes
No
*Patient's Last Name:
*First Name:
M.I.:
*Date of Birth:
Age:
Male
Female
Height:
Weight:
*Social Security #:
Driver's License #:
*Address:
*City:
*State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Zip:
How long have you resided at this address?
*Main Phone:
2nd Phone:
Email:
Marital Status:
Single
Married
Separated
Divorced
Widowed
Sports/Hobbies:
What is your primary concern/what would you like the orthodontist to address or evaluate?
Yes
No
Have you been treated or evaluated by an orthodontist before?
Dental Insurance Information
Insurance Company Name:
Insurance Co. Phone Number:
Policy Holder:
Policy Holder D.O.B.:
I.D. #:
Social Security #:
Group #:
Employer:
Job Title:
How long with current employer?
General Dentist Information
Name of Dentist:
Phone Number:
Date of last visit:
Reason:
Physician Information
Name of Physician:
Phone Number:
Relative/Spouse Information
First Name:
Last Name:
*Address:
*City:
*State:
*Zip:
Home Phone:
Cell Phone:
Work Phone:
Medical History
Please check if the patient has any of the following conditions either now or in the past. The answers you provide are for office records
only
and will be considered confidential.
Birth defects or hereditary problems
Bone fracture or any major accidents
Rheumatoid or arthritic conditions
Endocrine or thyroid problems
Kidney problems
Hepatitis, jaundice, or liver problems
AIDS/HIV+
STD's (Sexually Transmitted Diseases)
Fainting spells, seizures, epilepsy, or neurologic disease
Mental health or behavioral problems
Diabetes
Cancer or tumor treatment
Stomach ulcer or hyperacidity
Polio, mononucleosis, tuberculosis
Chest pain, shortness of breath, ankle swelling
Cardiovascular problems (Heart trouble)
Heart attack, angina, coronary insufficiency
Skin disorder
Do you have a good/normal diet?
Have you recently been under another dentist's care?
Frequent headaches, colds, sore throat
Eye, ear, throat condition
Tonsil or adenoid condition
Allergies or drug reactions
If applicable, list allergies/drug reactions:
Are you taking medication, nutrient supplements, or non-prescription drugs? If so, please list:
Do you currently have or have you ever had a substance abuse problem?
Operations
Hospitalizations (If yes, for what?)
Other physical problems or symptoms
Are you being treated by another healthcare professional?
Are you in good health?
Date of last physical:
Any recent weight loss or poor appetite
Excessive bleeding, black and blue tendency, or anemia
High or low blood pressure
Easily tired
Female Patients
Are you pregnant or could you be pregnant?
Are you taking birth control?
Are you anticipating becoming pregnant?
Dental History
History of supernumerary (extra) teeth or congenitally missing teeth
Permanent teeth removed
Aware of loose, broken, or missing restorations (fillings)
Any teeth irritating cheek, lip, tongue, or palate
Have you had periodontal (gum) disease?
History of speech problems
Hay fever, asthma, sinus trouble, or hives
Do you have any concerns regarding crooked, spaced, or protruding teeth?
Are you aware or concerned about an under or over developed jaw?
Do you have any relatives with similar tooth or jaw relationships?
Problems with wisdom teeth
Have you had any serious trouble associated with previous dental treatment?
Chipped or otherwise injured permanent teeth
Teeth sensitive to hot or cold
Jaw fractures, cysts, or mouth infections
"Dead teeth" or root canals treated
Bleeding gums, bad taste, or mouth odor
Periodontal (gum) problems
"Gum boils", frequent canker sores or cold sores
Thumb, finger, or sucking habit
Mouth breathing or tongue thrusting
Any pain in jaw or ringing ears
Have you ever been treated for TMJ problems?
Do you encounter difficulty in chewing or jaw opening/closing?
Abnormal swallowing habits
Do you experience any pain or soreness in the muscles of your face or around the ears?
How often do you brush?
How often do you floss?
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene; are there any restrictions, handicaps, or problems that might be encountered during treatment?
I understand the information I have given is true and correct to the best of my knowledge, it will be held at the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.
I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in this form.
I understand Credit Bureau information may be obtained for office payment plans.
Patient Signature:
Agreement to Receive Electronic Communication
I agree that the dental practice may communicate with me electronically at the email address below.
I am aware that there is some level of risk that third parties might be able to read unencrypted emails.
I am responsible for providing the dental practice any updates to my email address.
I can withdraw my consent to electronic communications by calling: 954-452-9988 OR info@jacarandasmiles.com
Patient/Legal Guardian Signature:
Acknowledgement of Receipt of Notice of Privacy Practices
* You May Refuse To Sign This Acknowledgement *
I have received a copy of this office's Notice of Privacy Practices.
Name:
Signature:
About ICAT CBCT Cone Beam Scans
Jacaranda Orthodontics and Pediatric Dentistry now offers an exciting new technology for our patients and for patients of other doctors who might be referred here. This technology is called I-Cat Cone Beam Computer Assembled Tomography (CBCT) imaging, sometimes called 3-D radiographs or x-rays. Using CBCT means we now have the ability to take 3D images of the teeth, jaws, bones and facial structures at lower costs and with less energy than a typical CT scan used in hospitals. 3D imaging provides us the opportunity of improved diagnosis for our patients, especially in cases of impacted teeth, dental implants, surgical treatment, as well as more complex cases. Understandably you may have questions about exposure to these types of x-rays. Here are some facts you should know about 3-D imaging.
An ICAT CBCT exposure is:
About 1/2 as much as a full series of x-rays
About 1/5 as much as a full (28) mouth series of standard dental x-rays
About 1/70 as much as a typical medical CT scan
CBCT therefore offers our patients enhanced diagnostic value at a significantly reduced exposure. At the same time, CBCT scans can image the entire head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws and surrounding supporting bone, using CBCT’s for those limited purposes.
Our training and dental license does not provide for evaluating and diagnosing outside those areas. However since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull or arteries. We can refer you to a radiology group for this purpose. The average cost is about $ $195.00. If you are interested in taking advantage of this service please initial the application section and sign the acknowledgement below.
YES, I want to have my I-Cat CBCT scans read by an oral radiologist and understand I am responsible for the additional costs.
NO, I understand the risks and benefits of having my CBCT read and interpreted by an oral radiologist, however I knowingly decline such a referral.
Signature of patient/responsible party: