Name
*
First Name
Last Name
I prefer to be called
Marital Status
Single
Married
Separated
Divorced
Widowed
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security #
Address
Home Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Sex at Birth
*
Male
Female
Prefered pronouns
She/Her
He/Him
They/Them
Phone Number
*
Email Address
*
example@example.com
Occupation
Employer
How did you find out about us?
Emergency Contact
Emergency contact
Relationship to Patient
Phone Number
Financial Responsibility (only fill out if it's other than yourself)
Who is financially responsible for this account?
Relationship to patient
Social Security #
Phone Number
Email
example@example.com
Employer
Address (if different from yours)
Home Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Dental Insurance
Primary policy holder's full name
Relationship to patient
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Address (if different from yours)
Home Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Insurance company
Insurance phone
Employer/Group Name
Group #
ID #
Secondary Dental Insurance (optional)
Primary policy holder's full name
Relationship to patient
Social Security #
Date of Birth
-
Month
-
Day
Year
Date
Address (if different from yours)
Home Address
Street Address Line 2
City, State, Zip Code
State / Province
Postal / Zip Code
Insurance company
Insurance phone
Employer/Group Name
Group #
ID #
General Information
What concerns you about your smile? Please check the boxes below.
*
Crowding
Extra Teeth
Teeth in the wrong position
Decreased lip support
Spacing
Teeth stick out too far
Poor bite relationship
Worn/misshapen teeth
Missing teeth
Type option 10
Gummy smile
Other
Have you had an orthodontic treatment evaluation or treatment before?
*
Yes
No
Who suggested that you might need orthodontic treatment?
*
What are you looking for in an orthodontist?
Is this your first consultation?
*
Do you have a treatment in mind? (Check all that apply)
*
Metal/Clear Braces
Aligners/Invisalign
Inbrace/Hidden Braces
I don't know; need to learn more
Do you have any upcoming life events that we should know about? (wedding, engagement, graduation, frequent travel schedule, 2+ week trip planned, speaking event, conference, family planning, etc.) Date and Event:
How often do you attend social events? (meals with friends/colleagues/client, work events, parties, dates, etc.)
5+ times a week
2-3x times a week
2-4x a month
Almost never
Have you ever received cosmetic and/or therapeutic treatment using neuromodulators such as Botox, Dysport, or Xeomin and/or fillers such as Juvederm, Restylane, etc?
Yes
No
Would you like to do a botox/filler consultation during your visit?
Yes
Some other time
Dental History
Dentist
*
Phone
Date of Last Cleaning
*
-
Month
-
Day
Year
Date
How often do you go to the dentist?
*
Please Select
2-3x a year
Once a year
Once every 2 years
Once eve
Are you anxious or nervous about dental treatment
*
Yes
No
Do you require premedication for dental treatment
*
Yes
No
Have you noticed any changes in your face or jaws
*
Yes
No
Do you feel any pain to any of your teeth?
*
Yes
No
Do you have any sores or lumps in or near your mouth?
*
Yes
No
Have you had any head, neck, or jaw injuries?
*
No
If yes, please describe
Do you have any on going problems with your face or jaws? (Select all that applies)
Difficulty chewing
Pain
Chronic clicking or popping
Difficulty opening or closing
None
Have you ever had speech therapy
*
Yes
No
Is there any outstanding dental treatment to be completed?
*
No
If yes, please describe
Do you have or have you had any of the following oral habits?
*
Nail biting
Clenching/Grinding
Thumb sucking
Biting lips/cheeks
Tongue thrust
Mouth breathing
None
Medical History
Physician
*
Date of last exam
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Are you taking medications including non-prescription medicine?
*
Yes
No
If yes, what medications are you taking?
Are you under medical treatment now?
*
Yes
No
Have you been hospitalized for any surgical operations or serious illness in the past five years?
*
Yes
No
Do you use tobacco?
*
Yes
No
Any allergies we need to be aware of? (medications, substances, metals)
*
Are you pregnant?
*
Yes
No
Please check all that apply:
*
Migraines/Frequent Headaches
Rheumatic Fever
Cold Sores
Diabetes/Low Blood Sugar
AIDS or HIV Infection
Cardiac Pacemaker
Heart trouble/defects
Cancer/Tumor
Joint Replacement/Implant
Hepatitis/Jaundice
Stomach Troubles/Ulcers
Asthma (Inhaler)
Fainting/Seizures
Endocrine/Thyroid Problem
High/Low B Blood Pressure
Radiation Therapy
Respiratory Problems
Epilepsy/Convulsions
Removal of Adenoids/Tonsils
Bone Fractures/Major Injuries
Arthritis/Joint Problems
Vision/Hearing/Speech Problems
Osteopenia/Osteoporosis
Birth defects/Hereditary problems
Mental Health Problems/Depression
Leukemia
Kidney/Liver Disease
Anemia
Sinus Problems
Stroke
Bone disorder
Glaucoma
Other
Authorization and Release
Please print your name
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Please print your name
Patient's name
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
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