Patient Information
Patient's Name:
Nickname:
Gender:
Select Gender
Male
Female
Age:
Birthdate:
Home Phone:
Address:
City:
State:
Zip Code:
Email Address:
Cell Phone:
General Dentist:
Last Visit Date:
Physician:
Last Physical Date:
I would like to receive appointment reminders by:
Email
Name on email account:
Patient
Parent 1
Parent 2
Other
Text
This phone belongs to:
Patient
Parent 1
Parent 2
Other
Whom may we thank for referring you to our office?
Any siblings or relatives treated here? Who?
Special interests or hobbies?
Patients 18 years or older:
Occupation:
Office Phone:
Employer:
Address:
City:
State:
Zip:
Name of Spouse (if applicable):
Patients younger than 18:
School:
Grade:
Height:
Weight:
Financially Responsible Parent:
Occupation:
Address:
Home Phone:
Employer:
Office Phone:
Email:
Cell Phone:
Parent 2:
Occupation:
Address:
Home Phone:
Employer:
Office Phone:
Email:
Cell Phone:
Marital Status of Parents
Parent 1 Relationship to Child?
Biological
Other
Guardian
Parent 2 Relationship to Child?
Biological
Other
Guardian
Medical/Dental History
Does the patient have now or have a history of any of the following? Please check all that apply.
allergies to medications
frequent colds/ear infections
clenching/grinding of teeth
Which ones?
handicaps/disabilities
sleep apnea
allergies to latex, plastic or metal
frequent headaches
mouth breathing
bone building medications
(Biophosphonates)
heart murmur/disease, HBP/defects
speech problems/therapy
arthritis (bone/joint disorders)
history of heart surgery
thumb/finger/lip sucking, tongue thrust
asthma (breathing disorders)
require antibiotics for dental visits
environmental allergies (dust, grass etc)
cancer
hemophilia (bleeding disorders)
smoking
cleft lip/palate
infectious diseases or exposure to TB/hepatitis/venereal disease/HIV/AIDS/blood transfusions
injury to face, mouth, teeth
convulsions/epilepsy
kidney or liver problems
learning disability
diabetes
surgery/operations
missing or extra permanent teeth
emotional problems
bone disorders or osteopenia
clicking/painful jaw joints
endocrine/thyroid/growth problems
periodontal disease/surgery
If the patient is under the care of a physician or taking any medications, please explain condition and list medications:
Is the patient currently or have ever taken any bone building/preserving or chemotherapeutic/Bisphosphonate medications (such as, but not limited to Actonel, Fosamax, Boniva, Aredia, Zometa, Skelid)?
Yes
No
Please advise us should you start taking these or other medications.
What are your primary concerns and expectations regarding your or your child’s orthodontic treatment?
Have you had previous orthodontic evaluations?
If yes, date of last visit?
Financial Information
(please bring your insurance card/form/referral for the receptionist - thank you)
Person(s) responsible for account
Relationship
Do you have dental insurance?
Yes
No
Do you have orthodontic coverage?
Yes
No
First Insurance Co. Name
Group# (Plan, Local, or Policy#)
ID #:
Ins. Co. Address
Phone
Policy Owner's Name
Birthdate
Relationship
Do you have secondary insurance?
Yes
No
I HAVE READ AND APPROVED OF THIS OFFICE'S NOTICE OF PRIVACY PRACTICES
Notice of Privacy Practices (
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