Patient Medical History Form(Adult)

Welcome to PERILLO ORTHODONTICS
Patient Information
Today's Date

MonthDayYear
Date
Patient Gender
Patient Name

First NameLast Name
Nickname
Patient Birth Date

MonthDayYear
Patient E-Mail
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Occupation/Student Status
Employer
Whom may we Thank for referring you?
Other family members seen by us
General Dentist
Last Dental Visit Date

MonthDayYear
Date
Account Holder Information
Person responsible for account

Other
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relation
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Primary Dental Insurance Information
Orthodontic Coverage
Insurance Company Name
Insurance Phone Number
Format: (000) 000-0000.
Claim Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Social Security Number
Policy Holder Employer
Policy ID number
Policy Group number
Please provide a picture of the front and back of your insurance card

Either take or upload a photo
Take a photo of the FRONT of your insurance card
Take a photo of the BACK of your insurance card
OR
Upload a photo of the FRONT of your insurance card

Browse Files

Cancelof
UPLOAD A PHOTO of the back of you insurance card

Browse Files

Cancelof
Secondary Dental Insurance Information
Orthodontic Coverage
Insurance Company Name
Insurance Phone Number
Format: (000) 000-0000.
Claim Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder

Other
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Social Security Number
Policy Holder Employer
Policy ID number
Policy Group number
Please provide a picture of the front and back of your insurance card

Either take or upload a photo
TAKE A PHOTO of the front of you insurance card
TAKE A PHOTO of the back of you insurance card
OR
UPLOAD A PHOTO of the front of you insurance card

Browse Files

Cancelof
UPLOAD A PHOTO of the back of you insurance card

Browse Files

Cancelof
Patient Medical History
What are the main concerns that you would like orthodontics to accomplish?

Are you allergic to any of the following?

Rows	YES	NO
LATEX
METAL
PLASTIC

Please list any drugs/materials that you are allergic to:
Have you ever been evaluated for orthodontic treatment?
Have you ever had orthodontic treatment?
Have there been any injuries to your face, mouth, teeth or chin?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you have any missing or extra permanent teeth?
Do you now or have you ever had any pain/tenderness in your jaw joint (TMJ/TMD)?
Do you like your smile?
Do your gums ever bleed?
Do you have a speech problem?
Do you generally breathe through your mouth?

Other
Do you smoke?
Have you ever taken Fosamax or any other bisphosphonate?
Please describe your current physical health:
Are you currently under the care of a physician?
If Yes, please explain.
Please list any current medications.
FOR WOMEN: Are you currently pregnant?
Physician Name/Phone number and Date of last visit

Have you ever had any of the following medical problems? (Please check all that apply)

Rows	YES	NO
ANEMIA
ASTHMA
ARTHRITIS
CANCER
ABNORMAL BLEEDING
DIABETES
EMOTIONAL DISORDER
EPILEPSY/SEIZURES
FAINTING SPELLS
ARTIFICIAL BONES/JOINTS/VALVES
HEART DISEASE
HEART ATTACK
RHEUMATIC FEVER
HIGH BLOOD PRESSURE
ULCERS
HEPATITIS
KIDNEY DISEASE
LIVER DISEASE
DRUG/ALCOHOL ABUSE
FEVER BLISTERS/HERPES
TUBERCULOSIS
VENEREAL DISEASE
NEUROLOGICAL DISORDERS
HANDICAPS/DISABILITIES
BLOOD TRANSFUSION
GLAUCOMA
HEART MURMUR
EMPHYSEMA
HEMOPHILIA
HIV/AIDS
MITRAL VALVE PROLAPSE
RADIATION TREATMENT
SEVERE/FREQUENT HEADACHES
SHINGLES
SICKLE CELL DISEASE
SINUS PROBLEMS
HOSPITALIZED FOR ANY REASON

Other illnesses:
Please explain any YES answers
Include other comments regarding your Medical History
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need.
Signature
INSURANCE ASSIGNMENT: If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. If my insurance was to terminate or there is a lapse in coverage, I understand that I would become responsible for the balance that my insurance does not pay. I hereby authorize payment of the group insurance benefits directly to this office. I authorize the use of this signature on all of my insurance submissions, whether manual or electronic.
Signature
PHOTO RELEASE: Perillo Orthodontics has my permission to use my photograph publicly to celebrate the practice. I understand that the images may be used in print publications, online publications, websites and/or social media. I also understand that no royalty, fee or any compensation shall become payable to me for any reason for such use.
I agree to the above terms regarding photo release
Signature
Should be Empty:

Patient Information

Account Holder Information

Primary Dental Insurance Information

Please provide a picture of the front and back of your insurance card

OR

Secondary Dental Insurance Information

Please provide a picture of the front and back of your insurance card

OR

Patient Medical History