Patient Information
Patient Name:
*
First Name
Last Name
Preferred Name:
Social Security Number:
Gender
*
Male
Female
Identifies as
Male
Female
Non-Binary
Birth Date:
*
Prefix
Mr
Mrs
Ms
Dr
Other
Marital Status
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:
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:
*
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 had other orthodontic treatment?
Yes
No
Orthodontist Name:
Have you ever experienced any sleep-related breathing disorders?
Mouth breathing
Snoring
Trouble breathing during sleep
Have you been treated for TMJ or TMD?
Yes
No
If yes, please provide details:
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 you ever had any periodontal (gum) 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 issues (select all that apply):
*
High decay rate
Malformed teeth
Missing teeth
Extra teeth
Poor oral hygenie
Neglect of gums
"White spots" on teeth
Gag Reflex
None of the above
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
Medical Physician Name:
Do you have a current medical condition
*
Yes
No
If yes, please explain:
Are you taking any medications, nutritional supplements or herbal medications at this time? Please list below
*
Yes
No
Medication, dosage, taken for:
Medication, dosage, taken for:
Medication, dosage, taken for:
Medication, dosage, taken for:
Have you ever taken medications for bone disorders or cancer such as bisphosphonates such as Fosamax, Actonel, or Boniva?
*
Yes
No
Have you had allergies or reactions to any of the following?
*
Latex
Aspirin
Ibuprofen
Penicillin
Local Anesthetics
Metals
Acrylics
Other
None of the above
if other, please list:
Do you smoke, vape or use tobacco in any form?
*
Yes
No
Are you pregnant?
Yes
No
Due Date:
Now, or in the past, have you had:
*
Emotional, sensory or developmental issues
Autism Spectrum Disorder (ASD)
Skin disorder (other than common acne)
Epilepsy, seizures
Diabetes
Endocrine, thyroid issues
Kidney disease
Tumor, Cancer
Serious Accident
Asthma, sinus problems
History of eating disorder
Autoimmune disorder
Heart problems, murmur
Arthritis, joint problems
History of osteoporosis
Liver disease, hepatitis
Herpes, STD
AIDS, HIV
Major surgery
Frequent ear infections, colds, throat infections
Frequent headaches or migraines
Vision, hearing or speech problems
Removal of adenoids or tonsils
None of the above
Any other conditions not mentioned above:
Have you had any unfavorable experiences in a dental office or have dental anxiety?
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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