DO - NP Form

Patient Information
Patient Full Name*
First and Last Name
Dentist*
Dentist Name & Practice
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred By*
Phone Number*
Please enter a valid phone number.
Is this a:*

CellHome
Hobbies / Interests
Date of Birth
School*
Student?*

YesNo
Grade*
1st Responsible Party Information
Name*
Relationship to Patient*
Marital Status

SingleMarriedDivorcedWidowed
Address
Home Phone
Cell Phone
Work Phone
Email
example@example.com
Employer
Occupation
Dental Insurance Carrier
SSN or ID Number
Group #
Subscriber Birthdate

MonthDayYear
Date
2nd Responsible Party Information
Name
Relationship to Patient
Marital Status

SingleMarriedDivorcedWidowed
Address
Home Phone
Cell Phone
Work Phone
Email
example@example.com
Employer
Occupation
Dental Insurance Carrier
SSN or ID Number
Group #
Subscriber Birthday

MonthDayYear
Date
If there are two responsible parties, in different households, with whom does the patient live primarily?
Is there a court order regarding insurance?
Medical History
Is patient in good health?

YesNo
Is the patient pregnant?

YesNo
Has patient been treated by a physician in the last two (2) years?
Is the patient taking any medications currently?
List any known allergies
Has the patient had any of the following:

AnemiaArthritisAsthmaDiabetesEpilepsyHeart MurmurHeart TroublesHepatitisKidney DiseaseLatex AllergyNervous DisorderProlonged BleedingRheumatic FeverTonsillitisTuberculosisOther
Dental History
Please check if there is history of any of the following:

Clenching/Grinding TeethExtra TeethFrequent HeadachesInjury to Head/Neck/JawJaw Joint PoppingMissing TeethMouth BreatherNose/Pain in Jaw/EarPreviously Treated TMJHistory of Thumb/Finger Sucking
If you selected 'History of Thumb/Finger Sucking, please indicate year stopped:
If the patient is a child, please list the names and ages of siblings:
Have others in the family received orthdontic treatment?
Has the patient had previous orthodontic treatment or consultation?
When did the patient last visit the dentist?
Please note specific problems you would like addressed:
I,blanks attest that the above information is true and accurate and authorize (if applicable) Datwyler Orthodontics to bill insurance for orthodontic treatment.
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YesNo
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Should be Empty:

Patient Information

1st Responsible Party Information

2nd Responsible Party Information

Medical History

Dental History