keller + wainwright orthodontics

1301 SUNNYVALE SARATOGA RD, SUITE 2. SUNNYVALE, CA 94087 PHONE (408) 739-4224

GABRIELLE WAINWRIGHT, DDS, MSD REBECCA KELLER, DDS, MSD

PLEASE FILL OUT THIS FORM AS COMPLETELY AS POSSIBLE AND EMAIL TO US PRIOR TO YOUR INITIAL ORTHODONTIC EXAMINATION APPOINTMENT
ABOUT YOU
Todays Date

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Please pick one:

Mr.Mrs.Ms.Dr.
Name

First NameLast Name
I prefer to be called (nickname)
Birthdate

MonthDayYear
Date
Age
Street Address
Apt
City
State
Zip Code
Years at this address
Soc Sec #
Cell Phone Number
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Work Phone Number
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Ext:
Email
example@example.com
Current Employer
Years Employed (at current employer)
Occupation
Whom may we thank for referring you to our office?
Please list other family members seen by us:
Who will be financially responsible for your treatment?
SPOUSE INFORMATION
His/Her Name
Street Address (if different from above)
Apt
City
State
Years at this address
Birthdate

MonthDayYear
Date
Employer
Years Employed
Occupation
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
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Work Phone Number
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Ext
Email
example@example.com
ORTHODONTIC INSURANCE
Is Orthodontic Coverage Available?

YesNo
Name of Insured
Relationship
Insurance Company Name
Phone
Insurance Company Address
Member ID or SSN
Is Secondary or Dual Insurance Coverage Available?

YesNo
Name of Insured
Relationship
Insurance Company Name
Phone
Insurance Company Address
Member ID # or SSN
MEDICAL INFORMATION
Physicians Name
Date of Last Visit

MonthDayYear
Date
Address
Phone Number
Please enter a valid phone number.
If currently under a Physicians care for what reasons
If taking any medications please list
Are you allergic to any medications?*
Do you require any medications prior to dental work?
Latex allergy?
Do you smoke or use tobacco in any form?

YesNo
Do you have any metal rods, pins, or implants?

YesNo
Have you ever taken phenfen also known as redux or pondimin? If so, when?
Have you ever taken Fosamax or any other bisphosphonate?
Have You Ever Had or Experienced Any of the Following?

NoneHeart DiseaseAbnormal Blood PressureRheumatic FeverAsthmaArthritisBleeding ProblemsAnemiaUlcersTuberculosis/ Lung diseaseVenereal DiseaseHepatitis / Liver ProblemsGlaucomaDiabetesCommunication disorderEpilepsyFrequent HeadachesNervous DisordersCancer or LeukemiaRadiation TherapyH.I.V. PositiveBone DisordersAllergiesSinus TroubleHay FeverHerpesHearing DisabilityLearning DisorderGrowth Disorders
If yes, please explain:
FOR WOMEN ONLY:
Are you pregnant?

YesNo
Are you nursing?

YesNo
DENTAL INFORMATION
Current Dentist's Name
City (of dental office)
Date of Last Visit

MonthDayYear
Date
Date of last X-Ray

MonthDayYear
Date
Type of X-Ray
Are You Currently Experiencing Dental Pain?
Have You Ever Had or Experienced Any of The Following?

Teeth sensitive to hot, cold, sweets or pressureTraumatic injury to teeth or mouthPain or tenderness around ear, joint, or side of facePain, Swelling, or Bleeding of GumsDifficulty in Opening/ClosingDifficulty in ChewingDifficulty in SwallowingDifficulty in SpeakingClicking or popping of jaw jointClenching or grinding of teethPeriodontal treatmentTMJ / Split treatmentUlcers / Cold soresPain, swelling, or bleeding gumsLoosening of Permanent teethNone of these
If yes, please explain:
Do you have any of these oral habits?

Thumb or finger suckingLip / Cheek bitingNail bitingMouth breathingTongue thrustNone of these
Are you nervous about having dental treatment?
Have you ever been diagnosed with sleep apnea?
Any missing or extra permanent teeth?
ORTHODONTIC INFORMATION
What is your primary concern about your teeth?
Do you have any concerns about orthodontic treatment?
Have you had other orthodontic consultations/ treatment?
If so, please name the Orthodontist(s)
Please describe the consultation or treatment
Have other family members had orthodontic treatment?
If so, please name the Orthodontist(s)
Please describe
Is there any additional information you would like us to know?
Signed

Clear
Date

MonthDayYear
Date
The information provided above may be used to obtain Insurance confirmation
Should be Empty:

ABOUT YOU

SPOUSE INFORMATION

ORTHODONTIC INSURANCE

MEDICAL INFORMATION

FOR WOMEN ONLY:

DENTAL INFORMATION

ORTHODONTIC INFORMATION