*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Birthdate:
*Email:
Employer/School:
Occupation:
*Home Phone:
Work Phone:
Cell Phone:
Who is your physician?
Who is your general dentist?
Date of last cleaning?
Referred to us by:

*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Email:
Previous Address (if less than 3 years):
S.S. #:
*Birthdate:
 
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
*Main Phone:
Work Phone #:
Spouse's Name:
Spouse's Employer:
Spouse's Occupation:
Work Phone:

Insurance Information

We will be happy to help you with your insurance, but we do not accept assignment of your benefits
Do you have orthodontic insurance?
Insured's Name:
Birthdate:
Insured's ID #:
Name of Insurance:
Insurance Address:
Insurance Phone:

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
I understand that where appropriate, credit bureau information may be obtained.

What are the patients or parents main concerns regarding the jaws and teeth?
Family members with similar problems?

Present Health
Physical
Emotional
Under Stress
Has the patient reached puberty?
Has the patient had any of the following conditions?

Medication. Current medications being taken by the patient?

Allergies to medication/food. The patient demonstrates an allergic response to:

Other Pertinent Information. Has the patient ever had a history of the following?
Clicking in Jaw Joint
Colds
Difficulty Chewing
Difficulty Swallowing
Finger Sucking
Grinding Teeth
Headaches
Lip Biting
Mouth Breathing
Pain in Jaw Joint
Smoking
Snoring
Sore Teeth
Sore Throats
Speech Problems
Thumb Sucking
Tonsillitis
Other Habits
Other

Regular Dental Checkups
Patient's Interest in orthodontic treatment
Orthodontic consultation was prompted by:
Has the patient ever had any unusual dental experiences?
Are there any medical, dental, surgical, or psychological problems not covered above?
Has the patient ever had a previous orthodontic consultation or treatment?
Name of Dr.
Why are you seeking this consultation?
Comments:
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibilty to inform this office of any changes in the medical history or status.