Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*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:
*How did you hear about us?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
*Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company below:
Employer:
Occupation:
Dental History
Dentist Name:
Has the patient had an orthodontic consult or treatment?
No
Yes
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Grind or clench teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Requires premedication?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
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
No
Yes
Tuberculosis/Lung Disease
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Hemophilia
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
History of Bisphosphonates
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Latex/Metal Allergy
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Handicaps/Disabilities
No
Yes
Asthma
No
Yes
Nervous Disorders
No
Yes
Treated for Emotional Problems
No
Yes
FEMALES: Are you pregnant?
No
Yes
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:
School:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative