Confidential Patient Information

*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell 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:
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:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

Policy Holder's Name:
Policy Holder Date of Birth:
Relationship to Patient:
Insurance Company:
Subscriber ID # or Social Security Number:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:
Do you have dual dental coverage?
  (If yes, complete information below)
Policy Holder's Name:
Policy Holder Date of Birth:
Relationship to Patient:
Insurance Company:
Subscriber ID # or Social Security Number:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Brushing Frequency:
Flossing Frequency:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste/mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Other:
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Bed wetting
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Low blood pressure
Persistent cough
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
Authorizations
  • I authorize my insurance company to pay the orthodontist all insurance benefits otherwise payable to me for services rendered. I authorize use of this signature on all insurance forms.
  • I authorize the orthodontist to release all information necessary to secure payment of benefits.
  • I authorize that I am financially responsible for all charges whether or not paid by insurance. (Charges may be incurred for the following: x-rays, study models, extractions, replacement retainers, etc.)
  • I authorize that by entering my name in the signature box below, I have consented to the above declarations.
Signature: