Patient Resources Forms - American Dental Care

Patient Details
Patient's Name*

First NameLast NameNickname
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*
Race*
Date of Birth*

MonthDayYear
Date
Age*
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
School/Employer
Grade/position
How did you hear about our office*
Email
example@example.com
Family members treated in our office
Reason for Consultation*
Previous Dentist*
Date of last cleaning

MonthDayYear
Date
Has the patient been examined by an orthodontist before?*

YesNo
If the Guardian & the Patient are the same person, please click here to copy patient information to the next page.
Guardian #1 / Insurance Information
For*

SelfSpouseFatherMotherStepparentOther (specify)
Guardian's Name*

First NameLast Name
Home Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Date of birth*

MonthDayYear
Date
Social Security Number*
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Guardian's E-Mail*
example@example.com
Insurance (If Applicable):
Company Name
Phone
Please enter a valid phone number.
Subscriber/Member ID
Guardian #2 / Insurance Information
Is there a second guardian and / or additional insurance to add?

YesNo
For*

SelfSpouseFatherMotherStepparentOther (specify)
Guardian's Name

First NameLast Name
Home Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Date of birth*

MonthDayYear
Date
Social Security Number*
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Guardian's E-Mail*
example@example.com
Insurance (If Applicable):
Company Name
Phone
Please enter a valid phone number.
Subscriber/Member ID
Sleep / Airway Issues
Does the patient tend to be a mouthbreather?

YesNo
Does the patient snore at night?

YesNo
Does the patient seem rested in the morning?

YesNo
Is the patient often sleepy during the day?

YesNo
Has the patient seen an Ear, Nose & Throat Specialist?

YesNo
Is the patient using a sleep apnea device?

YesNo
Dental/medical History
Please check if the patient has a history of the following medical conditions:
Acid Reflux

YesNo
ADHD/ADD

YesNo
AIDS/HIV

YesNo
Anemia

YesNo
Arthritis

YesNo
Asthma

YesNo
Autism

YesNo
Bone Disorders

YesNo
Cancer

YesNo
Cerebral Palsy

YesNo
Chest Pain

YesNo
Chronic Neck Pain

YesNo
Clicking of Jaw

YesNo
Jaw Pain

YesNo
Cold Sores/Herpes

YesNo
Diabetes

YesNo
Down Syndrome

YesNo
Endocrine Problems

YesNo
Emotional Disorders

YesNo
Epilepsy

YesNo
Headaches

YesNo
Heart Condition

YesNo
Hepatitis

YesNo
Ear Pain

YesNo
Immune Problems

YesNo
Kidney Problems

YesNo
Low Blood Pressure

YesNo
Muscular Disorders

YesNo
Nervous Disorders

YesNo
Organ Transplant

YesNo
Osteoporosis

YesNo
Painful Chewing

YesNo
Periodontal Problems

YesNo
Prolonged Bleeding

YesNo
Rheumatic Fever

YesNo
Scoliosis

YesNo
Seizures

YesNo
Sinus Problems

YesNo
TMJ Problems

YesNo
Tuberculosis

YesNo
Do your gums bleed when you brush?

YesNo
Is the patient seeing any other dental specialists?

YesNo
Specialists
Any dental restorations needing to be completed?

YesNo
Restorations
Have there ever been any injuries to the face, mouth or chin?

YesNo
Explain
Have you ever lost or chipped any teeth?

YesNo
Explain
Do you have any pain or soreness around your face, neck or back?

YesNo
Explain
Is any part of your mouth sensitive to temperature or pressure?

YesNo
Explain
Is the patient currently pregnant?

YesNo
Due Date
Have adenoids been removed?

YesNo
If Yes, When
Have tonsils been removed?

YesNo
If Yes, When
Currently taking any medications?

YesNo
List
Are antibiotics necessary prior to treatment?

YesNo
List
Allergies?

YesNo
If yes,
Any diseases or problems not mentioned above?

YesNo
List
Please check if the patient has, or ever had, any of the following habits?

Cheek, tongue or lip bitingClenching TeethFingernail BitingGrinding TeethTongue SuckingThumb SuckingTongue Thrusting
Signed Consent
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Signature*

Clear
Relationship to Patient*
Date

MonthDayYear
Date
If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:
By submitting this form you agree to the above mentioned consent statement
Should be Empty:

Patient Details

Guardian #1 / Insurance Information

Guardian #2 / Insurance Information

Sleep / Airway Issues

Dental/medical History

Signed Consent