FULL FORM

Welcome to Simply Orthodontics!

We’re so excited to meet you! Please fill this form as accurately as possible. Our office is paperless and we appreciate you doing this from home. This will also help you be seen for your appointment with minimal wait. Thank you.
Patient Information
Patient's Name *
Date of birth *

Month Day Year
Date
Responsible Party Information
Name: *
Relationship to Patient *
Relationship Status:
Cell Phone: *
Street Address: *
City: *
Zip Code: *
Email address *
Dental Insurance Information

Providing insurance information prior to your visit will allow us to give you the most accurate quote. We will not bill your insurance until you begin treatment with us. Please leave this section blank only if you do not have dental insurance.
Policy Holder's Name:
Relationship to Patient
Dental Insurance Company:
Date of Birth:

Month Day Year
Date
Employer:
Policy ID or SSN:
Group Number:
Please upload images of the front and back of your insurance card

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Dental History

It is important for us to coordinate with your dentist for your orthodontic treatment. We also want you to be up to date with all cleanings and restorative work prior to starting so that we make sure we are only moving healthy teeth.
Dentist Name: *
Last Dental Exam: *

Month Day Year
Date
Whom may we thank for referring you to our office? *
Reasons for wanting orthodontic treatment: *
Let Us See Your Teeth!

We will need photos of these 5 different angles of your teeth to better diagnose you. Please see the following examples:
Please upload all five images of your teeth

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Have you ever had an orthodontic consultation before? *
I understand that the information I have given on this form is accurate and I am obligated to inform Simply Orthodontics immediately of any future changes. I authorize Simply Orthodontics to provide my health care information to my other health care providers. I authorize release of any information regarding my orthodontic treatment to my dental and/or medal insurance company.
Signature of Patient (Parent/Guardian) *

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Photo Release Consent: I do hereby relinquish any and all rights to photographs, portraits, transparencies, native prints, polaroids or other photographic reproductions captured with still, motion picture, video, digital or other cameras for use by Simply Orthodontics.
Signature of Patient (Parent/Guardian)

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Date:

Month Day Year
Date
What Is Most Important to You?

We consider your satisfaction to be of utmost importance and we would like to personalize your orthodontic experience. Although we understand that all of these aspects are valuable, we can better customize your treatment based on your selections.
Please review the treatment aspects below and choose the TOP THREE that you find to be the most important.

Aesthetics: I would prefer it if people didn’t notice I am in orthodontic treatment. Colors: I want to display different colors on my braces. Length of Time in Orthodontic Treatment: I want to have a beautiful smile as quickly as possible. Visit Frequency: I want to come to see the orthodontist as few times as possible. Appointment Length: I want to sit in the chair for short periods of time during my visits. Schedule: I would like appointments to accommodate my own schedule (before or after school/work. Punctuality: I want to be seen on time for my appointments. Treatment Cost: I want the lowest possible treatment cost. Financing: I need the most flexible payment options possible.
Health History Questionnaire

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
Do you have any of the following?
Cardiovascular Health *

High blood pressure Angina or heart attack Chest pain on physical exertion Coronary artery blockage or treatment Heart valve problems or replacement Heart murmur Heart disease, problem or treatment Rheumatic fever Past use of Fen-Phem Irregular heart beat or pacemaker Diffuiculty breathing when lying down Low blood pressure None of the above
Endocrine/Blood/Immune Health *

Diabetes Frequent thirst or frequent urination Thyroid problems Abnormal bleeding, bruise easily Hemophilia Anemia/blood disease Cancer Radiation therapy/chemotherapy Cold sores/canker sores Organ treatment Blood transfusion None of the above
Respiratory Health *

Asthma Emphysema or respiratory problems Chronic sinus problems None of the above
Gastro-Intestinal/ Genito-Urinary Health *

Liver disease Kidney disease/dialysis Stomach trouble/ulcers Sexually transmitted disease None of the above
Muscular- Skeletal/ CNS/ Mental Health *

Joint replacement Arthritis Osteoporosis Seizures Numbness or muscle weakness Multiple sclerosis Intellectually disabled Dementia/Alzheimer's disease Anxiety/Nervousness Mental health treatment None of the above
Allergies *

Penicillin or other antibiotics Sulfa drugs Dental antesthetic Aspirin Codeine/ narcotics Iodine Latex products Metals/ nickels/ jewelry Anxiety/Nervousness None of the above
Do you have any medication allergies? *

Yes No Not Sure
Females Only
If the patient is a minor, has she started her first menstrual cycle? This helps us determine growth patterns

Yes No
If yes, approximately how long ago?
In months
Is the patient pregnant?

Yes No
Medications
Are you taking any prescription medications, over the counter medications or herbal medicines? *

Yes No
If so, please list them and the dose taken:
Do you or have you used bisphosphonate medication (Fosomax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa, Bonefos)? *

Yes No
Dental
Any unusual dental problems? *

Yes No
If yes, describe:
Pain or tenderness in gums or teeth? *

Yes No
If yes, describe:
History of pain in jaws or TMD or “TMJ” *

Yes No
If yes, describe:
History of previous orthodontic treatment? *

Yes No
If yes, describe:
Do you have any other medical conditions not already listed above? *

Yes No
If yes, describe:
Have you had any serious illness, operations or hospitalizations? *

Yes No
If yes, describe:
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errorsor omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Signature of patient or guardian *

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Date

Month Day Year
Date
Simon Shung, DMD Practice Limited to Orthodontics and Dentofacial Orthopedics 6246 Irvine Blvd Irvine, CA 92620 | p:949.264.3314 f: 888.975.4492 soirvine.com | info@soirvine.com
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Welcome to Simply Orthodontics!

Patient Information

Responsible Party Information

Dental Insurance Information

Dental History

Let Us See Your Teeth!

What Is Most Important to You?

Health History Questionnaire

Do you have any of the following?

Females Only

Medications

Dental