I ACKNOWLEDGE THAT I RECEIVED A COPY OF THIS OFFICE’S NOTICE OF PRIVACY PRACTICES.
I ACKNOWLEDGE
DATE
/
Month
/
Day
Year
Date
INITIALS
Patient
Name
First Name
Middle Name
Last Name
Male or Female
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Social Security #
Email
example@example.com
Address
ADDRESS
Street Address Line 2
city
state
zip
Home Phone
Format: (000) 000-0000.
Work Phone
Cell Phone
Cell Provider
Whom can we thank for referring you?
How did you hear about our office
Friend
Phone Book
Billboard
Newspaper
Dentist's Office
Internet
General Dentist
Last Dental Visit
Format: (000) 000-0000.
Main Concern/ Reason for Visit
School (if patient is child)
Grade Level
Family
FATHER’S (or husband’s) NAME
CELL PHONE
Format: (000) 000-0000.
CELL PROVIDER
ADDRESS (if different from patient)
HOME PHONE (if different from patient)
Format: (000) 000-0000.
EMPLOYER
HOW LONG?
WORK PHONE
Format: (000) 000-0000.
POSITION
EMAIL ADDRESS
example@example.com
MOTHER’S (or wife’s) NAME
CELL PHONE
Format: (000) 000-0000.
CELL PROVIDER
ADDRESS (if different from patient)
HOME PHONE (if different from patient)
Format: (000) 000-0000.
Employer
HOW LONG?
WORK PHONE
Format: (000) 000-0000.
POSITION
EMAIL ADDRESS
example@example.com
Responsible Party
Name
First Name
Middle Name
Last Name
YEARS AT CURRENT RESIDENCE
Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
MAILING ADDRESS
Street Address Line 2
city
state
zip
Home Phone
Format: (000) 000-0000.
Work Phone
Cell Phone
Cell Provider
Former Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
DATE OF BIRTH
/
Month
/
Day
Year
Date
Relationship to Patient
EMPLOYER
POSITION
NUMBER OF YEARS
Orthodontic Insurance
INSURED’S NAME
INSURED’S SOCIAL SECURITY
INSURANCE COMPANY
GROUP #
INSURED’S DATE OF BIRTH
/
Month
/
Day
Year
Date
INSURED’S PHONE
Format: (000) 000-0000.
Emergency
NEAREST RELATIVE NOT LIVING WITH YOU
RELATIONSHIP TO PATIENT
PHONE
Format: (000) 000-0000.
Complete Address
City
State
Zip
I realize it may be appropriate to utilize a credit report in determining a payment plan.
SIGNATURE (parent signature if patient is a minor)
DATE
/
Month
/
Day
Year
Date
Updates (date and initials)
Updates (date and initials)
Updates (date and initials)
Updates (date and initials)
Updates (date and initials)
NAME
DATE
/
Month
/
Day
Year
Date
Medical History
PHYSICIAN
AGE AT ONSET OF PUBERTY
Pregnant
Y
N
Medications
Allergies or Drug Sensitives
Y
N
If yes, explain
IN GOOD HEALTH?
Y
N
If no, explain
ANY MAJOR ILLNESSES?
Y
N
If yes, explain
Type a question
Anemia
Blood Disease
Diabetes
Hepatitis
Bone Disorders
Jaundice
Behavior Issues
Heart Disease/Murmur
Tuberculosis
Prolonged Bleeding
Endocrine Problems
Herpes
Epilespy
ADD/ADHD
Frequent Colds/Sinusitis
Tonsillitis
Mouthbreathing
Cancer/Radiation
HIV or AIDS
Osteoporosis Meds
Asthma
Artificial Joints, Value
Arthritis
Rheumatic Fever
Other
Tonsils Removed: Age
Adenoids Removed: Age
Dental History
SEVERE HEAD/FACE INJURIES?
Y
N
If yes, explain
Dental History (check all that are true)
PREVIOUS ORTHODONTIC CONSULTATION?
PREVIOUS TREATMENT FOR HEADACHES?
STRIKE SOME TEETH BEFORE OTHERS?
PREVIOUS ORTHODONTIC TREATMENT?
LOOSE TEETH / FOOD TRAPS?
SERIOUS/DIFFICULT DENTAL TREATMENT?
PREVIOUS TREATMENT FOR JAW PAIN?
FAVOR ONE SIDE WHEN CHEWING?
TOOTH SENSITIVITY? If so, please check 1 or more:
Heat
Cold
Sweets
Biting Pressue
Other
Joint History
Joint History (check all that are true)
Clenching Teeth
Dizziness
Ringing in Ears
Headaches
Jaw Joint Soreness
Muscles Soreness
Jaw Joint Clicking
Ear Pain
Grinding Teeth
Pain Upon Opening
Explain
I Wish The Following Could Be Done...
STRAIGHTEN FRONT TEETH
Upper
Lower
MOVE THE UPPER TEETH
Forward
Backward
MOVE THE MIDLINE OF THE TEETH
Upper
Lower
MOVE UPPER LIP
Forward
Backward
MAKE THE UPPER FRONT TEETH
Longer
Shorter
SHOW ____ When I Smile
More
Less
Teeth
Gums
MOVE THE LOWER TEETH
Forward
Backward
MOVE LOWER LIP
Forward
Backward
REDUCE STRAIN IN _____ WHEN CLOSING LIPS
Lips
Chin
MOVE CHIN
Forward
Backward
To Center
DATE
/
Month
/
Day
Year
Date
Signature (parent signature if patient is a minor)
Submit
Submit
Should be Empty: