*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:

*Please list the name and birthdate of any siblings:
Please list the names of any friends or family currently in the practice:
*Whom may we thank for referring you to our practice?
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
 
Relationship to Patient:
*Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Employer:
Occupation:
Dentist Name:
Has the patient had an orthodontic consult or treatment?

Please select YES if the patient has had any of the conditions listed below either now or in the past.
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Requires premedication?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
List any medications currently being taken by the patient:
List any 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.
Rheumatic Fever
Tuberculosis/Lung Disease
Liver Disease
Kidney Disease
Heart Disease
Congenital Heart Defect
Hemophilia
Prolonged Bleeding/Transfusion
HIV/AIDS
Hepatitis
History of Bisphosphonates
Cancer
Received Radiation Treatment
Latex/Metal Allergy
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Nervous Disorders
Treated for Emotional Problems
FEMALES: Are you pregnant?
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
School:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Patient's interest in treatment: