Patient's Name:
Nickname:
Address:
Home Phone:
Birth Date:
Siblings (Name and Age):
Emergency Contact:
Phone:
Relationship:
How did you hear about our office?

Primary Responsible Party

Marital Status:
Relationship to Patient:
Responsible for payment?
First Name:
Middle Initial:
Last Name:
Social Security:
Birthdate:
Address:
City:
State:
Zip:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone:
If you have orthodontic insurance:
ID #:
Insurance Company Name:
Group or Plan:
Insurance Company Phone:
Insurance Company Address:

Secondary Responsible Party

Relationship to Patient:
Responsible for payment?
First Name:
Middle Initial:
Last Name:
Social Security:
Birthdate:
Address:
City:
State:
Zip:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone:
If you have orthodontic insurance:
ID #:
Insurance Company Name:
Group or Plan:
Insurance Company Phone:
Insurance Company Address:
What do you want orthodontics to accomplish?
Dentist Name:
Last Visit Date:
Past dental or facial trauma
Explain:
Accidents or surgery to face, neck, mouth or teeth
Explain:
Teeth broken, loosened or knocked out
Explain:
Missing teeth
Explain:
Jaw joint problems
Explain:
Frequent headaches
Explain:
Clenching or grinding
Explain:
Oral problems
Explain:
Canker/cold sores
Explain:
Swollen/bleeding gums
Explain:
Habits: thumb/finger
Explain:
Speech
Explain:
Difficulty chewing or swallowing
Explain:
Previous orthodontic treatment or consultations
Orthodontist
Result
Family members had orthodontics
Orthodontist
Result
Does anyone in the family have a similar dental condition, crowded, retruded or protruded teeth, protruding lower jaw or receding chin?
Present Health:
Physician:
Ever been hospitalized
Explain:
Chronic diseases:
Explain:
Presently under physician care:
Explain:
Presently on medication:
Explain:
Allergies to latex or metal:
Other allergies:
Complications to previous treatment:
Explain:
Does the patient smoke or use tobacco?
Explain:
Does the patient have any of the following?
Any other diseases, conditions, or problems the orthodontists should know about?