Patient Biographical Information

* First Name:
* Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Preferred email address for appointment confirmation:
Please list the names of any friends or family who we have seen before:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Information

Name of Person Responsible:
Marital Status:
Relationship to Patient:
* First Name:
* Middle Initial:
* Last Name:
* Address:
* City:
* State:
* Zip:
Birthdate:
Social Security:
* Home Phone:
Work Phone:
Cell Phone:
Email:
Occupation:
Relationship to Patient:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Birthdate:
Social Security:
Home Phone:
Work Phone:
Cell Phone:
Email:
Occupation:

Insurance Information

Dental Insurance Company:
Address:
City:
State:
Zip:
Phone:
Policy Owner Name:
Relationship to Patient:
Policy Owner Birthdate:
Group #:
Insurance ID #:
Employer:
Dental Insurance Company:
Address:
City:
State:
Zip:
Phone:
Policy Owner Name:
Relationship to Patient
Policy Owner Birthdate:
Group #:
Insurance ID #:
Employer
Dental Insurance Co.
Address:
City:
State:
Zip:
Phone:
Policy Owner Name:
Relationship to Patient
Policy Owner Birthdate:
Group #
Insurance ID #:
Employer

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when? With who?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* Requires antibiotic premedication before dental appointment?
* Speech problems/therapy?
* Grind or clench teeth?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Injury to face, jaw, teeth or mouth?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Frequently Chew Gum?
* Mouth breathing?
* Snores during sleep?
* Apprehensive about dental care?
* Any missing or extra permanent teeth?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* Require Antibiotic Premedication
* Artificial Joints
* Latex/Metal Allergy
* Other Allergies
* Heart Trouble
* Rheumatic Fever
* Prolonged Bleeding
* Anemia
* Lung Disease/Tuberculosis
* Kidney Disease
* Liver Disease
* Hepatitis
* Immune Problems
* HIV/AIDS
* Tumors or Growths
* Endocrine Problems
* Diabetes
* Growth Problems
* Hormone Therapy
* Bone Disorders/Bone Loss
* Arthritis
* Seizures/Epilepsy
* Handicaps/Disabilities
* Hearing or Vision Impairment
* Tobacco Use
* Women: Are you pregnant?
* Ever Been Hospitalized
* Surgeries
* Tonsils/Adenoids Removed
* Other Condition Not Listed
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
School:
Grade:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

I understand the information that I have given is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in the patient's medical status.

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

* Name: