Zirbel Orthodontics Adult Health History Form

  • Zirbel Orthodontics Adult Health History Form

    Welcome to Zirbel Orthodontics!

  • Cassandra L. Zirbel, D.D.S., M.S.

    We would like to welcome you to our office. Our goal is to make every visit pleasant and educational. Please fill out the following information to assist us with your care and enhance customer service.
  • How did you hear about us?

  • Tell Us About You

    Please fill out the following information completely for accuracy with insurance, communication and HIPAA.
  • Marital Status:*
  • Birthdate:*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • I consent to receive text messages from Zirbel Orthodontics. Message frequency varies, msg & data rates may apply. Message types may include; appointment reminders and/or conversational messages. Reply STOP to opt-out. Reply HELP for help. View our Privacy Policy for Text Messaging Terms & Conditions.*
  • Birthdate of Insurance Policy Holder:*
     - -
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  • SECONDARY INSURANCE

  • Do you have secondary insurance? If yes, please answer the following questions. If you do not, please skip the rest of this section.*
  • Relation:
  • Birthdate of Insurance Policy Holder:
     - -
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  • Additional Information

  • Relation
  • Authorization to Discuss:
  • Birthdate:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are they the dental insurance policy holder? If not, please list name of holder.
  • Birthdate of Insurance Policy Holder:
     - -
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  • Person Responsible for Account

  • Please fill out only if information is not listed on previous pages.

  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Can we leave a detailed message?

  • Dental History

  • Have you ever had orthodontic treatment in the past?*
  • Have you been evaluated by another orthodontist recently?*
  • Have you been seen by this dentist in the last year?*

  • Have you ever had any of the following:

  • Speech Therapy?*
  • Do you have sleep apnea and use a CPAP machine?*
  • Have you worn a night guard appliance?*
  • Do you brush your teeth daily?*
  • Do you floss daily?*
  • Do you smoke or use tobacco?*
  • Have you been seen by a Periodontist?*
  • Have you been told you have periodontal disease?*
  • Has anyone in the family ever had jaw surgery?*
  • Have you been informed of any missing or extra permanent teeth?*

  • Medical History

  • Are your immunizations up to date?*
  • Please select all conditions that you currently have or have had in the past:*
  • Due date, if pregnant:
     - -

  • Authorization and Signature On File

    By Signing below, I authorize this office and it’s employees to use this form’s information to act as my agent to assist with insurance reimbursement and have insurance payments made directly to this office. 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.
  • Today's Date*
     - -

  • Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDA and ADA

  • Should be Empty: