Patient Information
Patient’s Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
-
Area Code
Phone Number
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Social Security #
Please list any hobbies or activities
Who may we thank for referring you to our office?
*
If patient is minor, give parent or guardian’s name
Patient Email
*
example@example.com
Responsible Party Email (If different from above)
example@example.com
Names & ages of any other children in the family
Responsible Party Information
Name
*
Marital Status
*
Single
Married
Divorced
Widowed
Residence
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
*
Previous Address (if less than 3 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
-
Area Code
Phone Number
Work Phone
*
-
Area Code
Phone Number
Social Security #
Birth Date
*
-
Month
-
Day
Year
Date
Relationship to Patient
*
Employer
*
Occupation
*
No. Years Employed
*
Spouse’s Name
Relationship to Patient
Spouse’s Employer
Spouse’s Occupation
No. Years Employed
Spouse’s Social Security #
Spouse’s Birth Date
-
Month
-
Day
Year
Date
Insurance Information
Do you have insurance?
*
Yes
No
Insured’s Name
*
Insured’s DOB
-
Month
-
Day
Year
Date
Insured’s Soc. Sec. #
Insurance Company
*
Group #
*
Local No.
*
Insurance Co. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have dual coverage?
*
Yes
No
Insured’s Name
Insured’s DOB
-
Month
-
Day
Year
Date
Insured’s Soc. Sec. #
Insurance Company
Group #
Local No.
Insurance Co. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured’s Employer
Emergency Information
Name of nearest relative not living with you
*
Complete Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Patient
*
Phone Number
*
-
Area Code
Phone Number
Medical History
Is the patient in good health?
*
Yes
No
Does the patient have any history of major illness?
*
Yes
No
Has the patient ever been under the care of a physician for illness?
*
Yes
No
If yes to any of the above, please list.
Select any of the following for which the patient has been treated:
*
Diabetes
Tuberculosis
Endocrine Problems
Pneumonia
Anemia
Prolonged Bleeding
Heart Trouble
Epilepsy
Fainting or Dizziness
Rheumatic Fever
Asthma
Nervous Disorders
Bone Disorders
Kidney Involvement
Liver Involvement
None
Does the patient have a tendency to:
*
Colds
Sore Throats
Ear Infections
None
Have tonsils and adenoids been removed?
*
Yes
No
If so, what age?
List any allergies or drug sensitivities:
*
Are you currently taking any medications?
*
Yes
No
If yes, please list:
Girls: Has she started menstruation? Boys: Has his voice changed?
*
Yes
No
Girls: (if yes) date of first menstrual cycle?
Height
Weight
Has there been any injuries to the face, mouth, or teeth?
*
Yes
No
Has the patient ever sucked a thumb or fingers? (If yes, until what age?)
*
Does the patient have any speech problems?
*
Yes
No
Is the patient a mouth breather?
*
While Awake?
While Asleep?
No
Have you been informed of any missing or extra permanent teeth?
*
Yes
No
Has an orthodontist been consulted previously?
*
Yes
No
Has either parent had orthodontic treatment?
*
Yes
No
Reason for consultation:
*
Dentist Name
*
Date of last visit?
*
-
Month
-
Day
Year
Date
Notice Of Privacy Practices
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Signature
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*
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