Patient Information
Patient Name:
*
First Name
Last Name
Preferred Name:
Social Security Number:
Gender
*
Male
Female
Identifies as
Male
Female
Non-Binary
Birth Date:
*
Mr.
Mr
Mrs
Ms
Dr
Other
Single
Single
Married
Divorced
Widowed
Partner
Home Address:
*
City:
*
State:
*
Zip:
*
Primary Phone Number:
*
Phone Type
*
Home
Cell
E-mail:
*
How would you like to receive appointment reminders?
Email
Text
If text, please enter text number:
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Financial Responsibility Information
(IF DIFFERENT FROM PATIENT INFORMATION ABOVE)
Name:
Single
Single
Married
Divorced
Widowed
Partner
Address (if different than patient):
City:
State:
Zip:
Primary Phone:
home
Home
Cell
E-mail:
Emergency Contact Information
Emergency Contact's Name:
Phone Number:
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Dental Insurance Information
Primary Insurance Company:
Phone Number:
Group Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:
Employer:
Secondary Dental Insurance Information
Secondary Insurance Company:
Phone Number:
Group Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:
Employer:
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Dental History
General Dentist Name:
*
Last Visit:
How did you hear about our practice
Ad
Internet
Family/Friend
Dentist
Other
Name of person referring (if applicable):
What are the main concerns you would like orthodontics to correct?
*
Have you visited an orthodontist before?
Yes
No
If yes, when:
Orthodontist Name:
Have we treated other members of your family?
Yes
No
Name(s):
Do you snore or have sleep apnea?
Yes
No
Have you been treated for "TMJ" or "TMD"?
Yes
No
Have you ever had an injury to your teeth?
Yes
No
How frequently do you brush your teeth?
Do your gums bleed with brushing?
Yes
No
Have your tonsils or adenoids been removed?
Yes
No
Have you ever had any periodontal surgery?
Yes
No
If yes, please provide details:
Have you ever had any oral surgery?
Yes
No
If yes, please provide details:
Do you have any jaw problems (select all that apply):
*
Clicking of jaw
Jaw pain
Difficulty in chewing
Clenching or grinding
Stiff jaw on awakening
Jaw stuck open/closed
Difficulty open/closing
None of the above
Do you have any of the following oral problems (select all that apply):
*
High decay rate
Malformed teeth
MIssing teeth
Extra teeth
Poor oral hygenie
Neglect of gums
"White spots" on teeth
None of the above
Other oral problems:
Do you have any of the following habits (select all that apply):
*
Lip sucking
Thumb/finger sucking
Lip biting
Constant mouth breathing
Nail biting
Tongue thrusting
Grinding
None of the above
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Medical History
Are you currently being treated by a physician?
*
Yes
No
Reason:
Physician Name:
Last Visit:
Do you have a current medical condition
*
Yes
No
If yes, please explain:
Are you taking any medications at this time
*
Yes
No
What type and dosage (if yes to the above questions):
Now or in the past, have you taken medications known as "Bisphosphonates"?
*
Yes
No
Have you had allergies or reactions to any of the following? (select all that apply)
*
Aspirin
Ibuprofen
Latex
Codeine
Local Anesthetics
Erthromycin
Penicillin
Other
None of the above
if other, please list:
Do you smoke or use tobacco in any form
*
Yes
No
Are you pregnant?
*
Yes
No
Due Date:
Now, or in the past, have you had:
*
Hearing difficulties
Fainting or dizziness
Diabetes
Kidney disease
Frequent headaches
Epilepsy or seizures
Breathing problems
Tumor, Cancer
Serious Accident
Ulcers
Speech difficulties
Poor vision
Blood problems
Heart problems, murmur
Arthritis
Cerebral palsy
Birth defects
Blood transfusion
Stomach problems
Emotional difficulties
Liver disease or hepatitis
Bone/joint problems
Autoimmune disorder
Skin problems
Sinus problems
Herpes virus
Major surgery
Head or neck pain
None of the above
Any other condition not mentioned above:
Do you have a history of allergies?
*
Yes
No
If yes, please explain:
Have you had any unfavorable experiences in a dental or medical office?
Yes
No
If yes, please describe:
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AUTHORIZATION
I understand that the information that I have given is correct to the best of my knowledge, and that it will be held in the strictest confidence. I understand it is my responsibility to inform this office of any changes in the patient's medical/dental status. I authorize the orthodontic staff to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's dental needs.The office reserves the right to conduct a Credit Check. I understand I am financially responsible whether my insurance company pays or not, for all charges incurred. I further agree that in the event of nonpayment, I will bear the cost of collection and/or court costs and reasonable legal fees should such action be required.
Signature
Date:
*
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