Tolleson Orthodontics - New Patient Form

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Patient Information
Items marked with asterisk (*) must be completed.
Patient's Name*

First NameMiddle NameLast Name
I prefer to be called (Nickname)
Gender*
Birthdate*

MonthDayYear
Address:*

Street

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Work Phone
Email*
example@example.com
Whom may we thank for referring you to our office?*
How else did you hear about us?
School (if a student)
Other family members seen by us
Responsible Party Information

If patient is under 18, please complete this section
Name

First NameLast Name
Relationship to Patient
Mailing Address: (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell/Phone
Email Address
Birthdate

MonthDayYear
Employer/Occupation
Spouse's Name
Spouse's Employer/Occupation
Spouse's Date of Birth

MonthDayYear
Spouse's Cell/Other Phone
Spouse's Email Address
Dental Insurance Information
Do you have Dental Insurance?*
Save time in office by uploading a snapshot of the front and back of your insurance card.

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Insured's Name

First NameLast Name
Insured's Date of Birth*

MonthDayYear
Date
Insured's employer
Insured's SS Number (U.S. only)*
Member/Insured ID Number
Insured Company
Group Number
Insured Phone Number
Emergency Information
Who should we contact in the case of an emergency?*
Relationship to patient*
Phone *
Please enter a valid phone number.
Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Does the patient have any major illnesses:*
If Yes, please list illnesses:
Has the patient ever been under the care of a physician?*
Please list:
Have tonsils & adenoids been removed?*
If Yes, at what age?
Is the patient in good health?*
Please check any of the following conditions or problems as it pertains to the patient's medical history.

AsthmaAllergies/Hay FeverArthritisBirth defectsBlood disordersBone disorders or fractureCancerCardiovascular DiseaseDiabetesEmotional DisorderEndocrine/Hormone ProblemsEpilepsyExcessive BleedingEye disorderFainting/dizzinessHearing ProblemsHeart Murmur/TroubleHepatitisHerpesHigh Blood PressureHip/Joint ReplacementHIV/AIDSKidney or Liver TroubleMumpsPregnant currently?Radiation/ChemotherapyRheumatic FeverSeizuresSpeech DisorderTuberculosis
List any allergies or drug sensitivities:
Please list any drug or medications now being taken along with reasons for each:
Dental History
General Dentist*
Date of last visit*

MonthDayYear
Date
What concerns you most about your teeth?
Please check any of the following which apply to you, and add any relevant comments.
Are you presently in any dental pain?*
Comment:
Any history of periodontal treatment or gum disease?*
Comment:
Have there been any injuries to face, mouth or teeth?*
Comment:
Has the patient ever sucked a thumb or fingers?*
If yes, at what age?
Does the patient have any speech problems?*
Comment:
Is the patient a mouth breather?*
If yes, while awake or asleep?
Have you been informed of any missing or extra permanent teeth?*
Has either parent had orthodontics treatment?*
Has an orthodontist been consulted previously?*
If yes, who?
Any history of TMJD (clicking, popping, pain in the jaw joint)?*
Any history of clenching or grinding of the teeth?*
Any objections or concerns to orthodontic treatment?
What do you hope to accomplish with orthodontic treatment?
Patient or Guardian Signature*

Clear
Date*

MonthDayYear
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge.

All information is confidential and is accessed only via a secure, encrypted interface.
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Submit Your Health History Form Online With Secure Encryption

Patient Information

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Dental History