Preferred Name
Name
*
First Name
Middle Initial
Last Name
Sex
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
School attends
Social Security #
Patient lives with whom/Relationship
Who has legal custody of patient?
Whom may we thank for referring you?
Responsible Party
Status
Married
Separated
Divorced
Single
Widowed
Mother's name
Date of Birth
-
Month
-
Day
Year
Date
Social Security #Number
Address
Address
City, State, Zip Code
How long at this address?
Phone Number
Please enter a valid phone number.
Employer
Years Employed
Occupation
Email Address
example@example.com
Father's name
Date
-
Month
-
Day
Year
Date
Social Security #Number
Address
Address
City, State, Zip Code
How long at this address?
Phone Number
Employer
Years Employed
Occupation
Email Address
example@example.com
Who will be responsible for bringing the patient to orthodontic appointments?
Emergency Contact
Full name
Relationship to patient
Phone Number
Please enter a valid phone number.
Dental Insurance
Primary policy holder's full name
Relationship to patient
Suscriber ID/Social Security #
Birthdate
/
Month
/
Day
Year
Date
Insurance company
Insurance phone
Employer/Group Name
Group #
Secondary Dental Insurance (optional)
Primary policy holder's full name
Relationship to patient
Suscriber ID/Social Security #
Birthdate
/
Month
/
Day
Year
Date
Insurance company
Insurance phone
Employer/Group Name
Group #
General Information
What concerns do we have with their smile?
Crowding
Extra Teeth
Teeth in wrong position
Decreased lip support
Spacing
Teeth stick out too far
Poor bite relationship
Worn/misshapen teeth
Missing teeth
TMJ problems
Gummy smile
Other
Who suggested that they might need orthodontic treatment?
4. Have they had any previous orthodontic treatment? Please describe.
Do you think that any of their school or leisure activities affect your teeth or jaws? Please explain.
Dental History
Dentist
Phone
Date of last cleaning
/
Month
/
Day
Year
Date
Are they anxious or nervous about dental treatment?
Yes
No
Have you noticed any changes in their face or jaws?
Yes
No
Any ongoing problems with jaws? Such as clicking/popping, difficulty chewing/opening or closing?
Yes
No
Do they feel any pain to any of their teeth?
Yes
No
Do they clench or grind their teeth?
Yes
No
Do they bite their lips or cheeks frequently?
Yes
No
Are there any outstanding treatment to be completed?
No
Yes, please describe
Any oral habits such as nail biting, thumbsucking, tongue thrust while swallowing, mouth breathing, etc?
No
Yes, please describe
Medical History
Please Read: We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, bipolar disorder, autism, etc.
Physician
Phone Number
Please enter a valid phone number.
Date of last exam
-
Month
-
Day
Year
Date
Are they under any medical treatment now?
Yes
No
Have they been hospitalized for any surgical operations or serious illness in the past five years?
No
Yes, please describe
Are they taking any medication including non-prescription medicine?
No
Yes, please indicate
Are there any allergy to medications or substance, including metals we should know about?
No
Yes, please describe
Please check all that apply:
Cold Sores
Cardiac Pacemaker
Joint Replacement/Implant
Asthma (Inhaler)
High/Low B Blood Pressure
Epilepsy/Convulsions
Arthritis/Joint Problems
Birth defects/Hereditary problems
Kidney/Liver Disease
Stroke
Migraines/Frequent Headaches
Diabetes/Low Blood Sugar
Heart trouble/defects
Hepatitis/Jaundice
Fainting/Seizures
Radiation Therapy
Removal of Adenoids/Tonsils
Vision/Hearing/Speech Problems
Mental Health Problems/Depression
Anemia
Bone disorder
Rheumatic Fever
AIDS or HIV Infection
Cancer/Tumor
Stomach Troubles/Ulcers
Endocrine/Thyroid Problem
Respiratory Problems
Bone Fractures/Major Injuries
Osteopenia/Osteoporosis
Leukemia
Sinus Problems
Glaucoma
Other
Authorization and Release
Print Name
Relationship to Patient
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Please print patient's name
Please print your name
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
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