Patient's full name:
Prefers to be called:
Patient's Address:
Home Phone:
Cell Phone:
Patient's Birthday:
Patient's Dentist:
Date Last Visited:
Whom may we thank for referring you?
Name(s) and age(s) of children:
Other family members seen by us:
Your Employer:
Social Security Number:
Your occupation:
Work Phone:
Spouse's Name:
Spouse's Employer:
Work Phone:
Spouse's Occupation:
Cell Phone:
Emergency Contact (if different than spouse):
Insured's Name:
Insured's SSN:
Insured's Employer:
Insured's Birthday:
Insurance Company Name:
Insurance Phone #:
Insurance Company Address:
Group Number:
ID Number:
Relationship to patient:
Please explain all checked responses:
List any allergies:
List any medications:
Have you ever been told you need to pre-medicate before a dental apppointment?
Please explain all checked responses:
Please list your chief concern(s) and what you would like treatment to accomplish:
Has patient ever been by any previous orthodontist? If yes, complete below.
Last seen:
Treatment Started: