*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Marital Status:
List Siblings:

Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?

#1 Responsible Party
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
Relationship to Patient:
Email:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Marital Status:
Employer:
Occupation:

2nd Responsible Party
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
*Address:
*City:
*State:
*Zip:
Main Phone:
2nd/Cell Phone:
Marital Status:
Employer:
Occupation:
Insurance Company:
Insurance Phone No.:
Subscriber's Name:
Birthdate of the Primary Insured:
Subscriber Social Security or Member ID #:
Group #:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, please specify when and why?
*What is the patient's main orthodontic concern?
Are you interested in Invisalign treatment?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Grind or Clench Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throat?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Physician Phone #:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Premedicate
High or low blood pressure
Airway problems (Tonsils/adenoids/sinus headaches)
Diabetes
Headaches
Nervous disorder
Take tranquilizers or sedatives
Asthma
Use of an inhaler
Arthritis
Tumors or cancer
Have you ever taken any bisphosphonates?
Involvement in a serious accident
Allergies (please specify)
Please list all medications
Anything you would like us to know about your medical history or other conditions?
For women:
Are you pregnant?