Patient Health History Form

Patient Health History Form

Save time at the orthodontic office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You may need to provide a signature at the office to verify that the information you submitted online is accurate.
Patient Information
Name*

First NameLast Name
I prefer to be called
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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/Other*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Birth date*

MonthDayYear
Date
Age
MaleFemale
Social Security Number (U.S. Only)
Whom may we thank for referring you to our office?
Other family members seen by us:
Responsible Party Information
Relationship to Patient
Full Name

First NameLast Name
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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/Other*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
If patient is under 18, please complete this section.
Social Security Number (U.S. Only)
Birth date

MonthDayYear
Date
Employer
Occupation
Number of Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security Number (U.S. Only)
Birth date

MonthDayYear
Date
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/Other
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Dental Insurance Information
Insured's Name

First NameLast Name
Insured's Social Security Number (U.S. Only)
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Insured's Name

First NameLast Name
Insured's Social Security Number (U.S. Only)
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Information
Name of nearest relative not living with you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Physician
Date of Last Visit

MonthDayYear
Date
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please check any of the following which apply to you, and add any relevant comments.
YesNo
List any medications you are currently taking:
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment

Please check any of the following that you have had or currently have:*

Rows	Yes	No
Abnormal Bleeding/Hemophilia
ADD/ADHD
Anemia
Arthritis
Asthma or Hay Fever
Autism
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
Latex or Metal Allergy
Pneumonia
Nervous Disorders
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor/Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?
Patients Under 18

If patient is under the age of 18, please answer the following questions:
Patient Height
Patient Weight
School
Grade
YesNo
YesNo
YesNo
YesNo
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you the most about your teeth? Do you like your smile?
Please check any of the following which apply to you, and add any relevant comments.
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
YesNo
Comment
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.
Should be Empty:

Patient Health History Form

Patient Information

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Patients Under 18

Dental History