*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:

Please list the names of any family currently in the practice:
List any sports, hobbies, or musical instruments played:
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:
Social Security #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber Social Security:
Subscriber Birthdate:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber Social Security:
Subscriber Birthdate:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
 
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?

Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of last Physical:
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
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:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name: