Patient Information

* First Name:
MI:
* Last Name:
* Gender:
* Address:
* City:
* State:
* Zip:
Cell Phone:
* Home Phone:
* Birthdate:
If patient is a minor, give parent's or guardian's name:
Responsible Party Email:
Who is accompanying the patient today:
Relationship to Patient:
Names and ages of siblings/children:
Whom may we thank for referring you to our practice?

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Marital Status:
* Residence:
* City:
* State:
* Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Cell Phone:
* Home Phone:
Work Phone #:
Previous Address (if less than 3 years)
Social Security #:
* Birthdate:
Relationship to Patient:
* Employer:
Occupation:
No. Years Employed:
Spouse Information
First Name:
Middle Initial:
Last Name:
Employer:
Occupation:
No. Years Employed:
Cell Phone:
Home Phone:
Social Security #:
Birthdate:

Insurance Information

Insured's Name:
Birthdate:
SS #:
Insurance Company:
ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
  Do you have dual dental coverage? 
     (If yes, complete information below)
Insured's Name:
Birthdate:
SS #:
Insurance Company:
ID #:
Group #:
Insurance Co. Phone No.:
Insured's Employer

Emergency Information

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

Medical History

* Is the patient in good health?
* Does the patient have a history of illness?
* Has the patient ever been under the care of a physician for illness?
* Have the tonsils and adenoids been removed?
* Has patient EVER taken Biophosphonate drugs? (usually taken for osteoporosis)
Is there a possibility that the patient is pregnant?
CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAS BEEN DIAGNOSED
Please discuss any medical problems:
Does the patient have a tendency to get:
List any drugs or medications being taken, give reasons:
List any allergies or drug sensitivities:

Dental History

Dentist Name:
Date of Last Cleaning:
Any dental work pending?
* Does the patient require premedication for dental procedures?
* Injury to face, jaw, teeth or mouth?
* Pain, tenderness in the jaw joint (TMJ)?
* Has the patient ever sucked a thumb/finger?
* Does the patient have any speech problems?
* Has puberty begun (menstruation for girls):
* Is the patient a mouth breather while awake?
* Is the patient a mouth breather while asleep?
* Have you been informed of missing or extra permanent teeth?
Has either parent ever had orthodontic treatment:
Reason for consultation:
What would you like orthodontics to accomplish for you:

Benefits/Signature

Benefits of orthodontics: Aesthetics, Health and function. Orthodontics is a service that provides an improvement in the appearance of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I understand this paragraph, and I also understand that it is my responsibility to inform this office of any changes in the patient’s medical status.

The information I have given is correct to the best of my knowledge, and it will be held in the strictest of confidence. I authorize Dr. Shae Ochoa and dental staff to perform the necessary dental services needed.

Signature:
Relationship to Patient: