Confidential Patient Information

* First Name:
MI:
* Last Name:
Nickname:
* Address:
* City:
* State:
* Zip:
* Birthdate:
* Gender:
Under 18
School:
Grade:
* Main Phone:
2nd/Cell Phone:
Email:
Primary method of contact:

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:
Sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)
Teeth - If your teeth could be changed, how would you like them to change?
Face - If your facial appearance could be changed, what would you change?

Confidential Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Email:
Preferred method of contact:
* Birthdate:
Relationship to Patient:
Employer:
Occupation:
Work Phone #:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Preferred method of contact:
Employer:
Occupation:
Birthdate:
Work Phone #:
Relationship to Patient:

Dental Insurance Information

Policy Holder's Name:
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:
Policy Holder's Employer:
Relationship to Patient:

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

Emergency Contact

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

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
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 check only those the patient has now or has had in the past.
If any of the above TMD questions were 'checked', please explain:
If any of the above dental questions were 'checked', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

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:
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please check only those the patient has now or has had in the past
If any of the above medical questions were 'checked' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
If patient is a girl, has menstruation begun:
Has either biological parent ever had orthodontic treatment:
Name of person completing this form:
Relationship to Patient:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or midical or dental status, I will inform the practice.