Patient Information
Patients under 18 years of age
Date
-
Month
-
Day
Year
Date
Patient's Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nickname
Birth Date
-
Month
-
Day
Year
Date
School
Sports / Hobbies
Parent / Guardian Name
Email
example@example.com
Whom may we thank for referring you to our office?
Billing Party Information
Name
First Name
Middle Name
Last Name
Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Previous Address (If less than 3 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
Date
Relationship to patient
Employer
Occupation
No. of years employed
Additional billing party name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Occupation
No. of years employed
Dental Insurance
Policy Holder Name
DOB
-
Month
-
Day
Year
Date
Insurance Company
Subscriber ID #
Group #
Insurance Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have dual insurance coverage?
*
Yes
No
Policy Holder Name
DOB
-
Month
-
Day
Year
Date
Insurance Company
Subscriber ID #
Group #
Insurance Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Information
Name of nearest relative not living with you
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Misc. Info
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Medical History
Physician
Date of last visit
-
Month
-
Day
Year
Date
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please choose Yes or No (if Yes, please fill in details)
Rows
Yes
No
Details
Is the patient taking any medication?
Is the patient allergic to any medication?
Does the patient have a history of a major illness?
Has the patient had any operations?
Has the patient ever been involved in a serious accident?
Has the patient seen a physician in the last 12 months?
Female Patients ONLY
Rows
Yes
No
Explain
Has menstruation started?
Is the patient pregnant?
Check any of the medical conditions below that the patient has had or currently has
Abnormal bleeding / Hemophilia
Anemia
Arthritis
Asthma or Hay Fever
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis / Liver Problems
Herpes
High Blood Pressure
HIV / AIDS
Kidney Problems
Nervous Disorder
Pneumonia
Prolonged Bleeding
Radiation / Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor / Cancer
Are there any medical conditions we have not discussed that you feel we should bbe aware of?
Dental History
General Dentist
Date of last visit
-
Month
-
Day
Year
Date
What concerns you most about the patient's teeth?
Please choose Yes or No (if Yes, please fill in details)
Rows
Yes
No
Details
Is the patient presently in any dental pain?
Has the patient experienced any unfavorable reaction to dentistry?
Has the patient ever lost or chipped any teeth?
Has the patient had any injuries to the face, mouth or teeth?
Is any part of the patient's mouth sensitive to temperature? Where?
Is any part of the patient's mouth sensitive to pressure? Where?
Do gums bleed when brushing?
Any type of thumb or tongue habit?
Is the patient a mouth breather?
Has the patient ever seen an orthodontist? If yes, who and when?
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Does the patient experience aw clicking or popping?
Aware of any clenching or grinding teeth during the day?
Experience "tension" headaches?
Has the patient ever experienced chronic ringing in the ears?
Does the patient need extra help with instructions?
Is the patient sensitive or self-conscious about his/her teeth?
Are you aware that some appointments will be during daytime hours?
Has anyone in the family received orthodontic treatment?
How do they feel about the result?
What is the patient's attitude toward receiving orthodontic treatment?
Mother's Height
Father's Height
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: