scottorthodontics.com

Patient Information
Patient Name:

First NameLast Name
Gender:
Social Security Number:
Birth Date:

MonthDayYear
Date
Age:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:
OK to leave message?
E-mail: (Required)
example@example.com
Employer's Name:
Occupation:
Spouse / Partner Information
Spouse/Partner's Name:

First NameLast Name
Marital Status:

Significant Other
Social Security Number:
Birth Date:

MonthDayYear
Date
Driver's License Number:
Address (if different than patient):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:
Secondary Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:
Emergency Contact Information
Emergency Contact's Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Patient:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) OK to release appointment or medically-related information to:
Relation to Patient:
Insurance Information
Primary Insurance
Primary Insurance Company:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Group Number:
Policy Number:
Member ID Number:
Co-pay (if known):
Deductible (if known):
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:

MonthDayYear
Date
Employer:
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insurance
Secondary Insurance Company:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Group Number:
Policy Number:
Member ID Number:
Co-pay (if known):
Deductible (if known):
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:

MonthDayYear
Date
Employer:
Work Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Dental History
General Dentist:
Last Visit:
How did you hear about our practice?

Other
Name of person referring(if applicable) :
What are the main concerns you would like orthodontics to correct?
Have you visited an orthodontist before?
If yes, when?:
Reason:
Have your tonsils or adenoids been removed?
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any missing or extra permanent teeth?
Have you ever had an injury to (select all that apply):
Do you have speech problems?
If so, explain:
Do your gums bleed?
Do you smoke?
Do you like your smile?
Do you currently or have you ever had any of the following habits(check all that apply):
Medical History
Are you currently being treated by a physician?
Reason:
Physician:
Last Visit:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any allergies/sensitivities to medications or latex?
If yes, please list:
Are you currently taking any prescription or over-the-counter medications?
If yes, please list with the dosage:
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
If yes, give approximate dates:
(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Check if you have ever had any of the following:
Authorization
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.
Submitted by:
Date:

MonthDayYear
Date
Should be Empty:

Patient Information

Spouse / Partner Information

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Dental History

Medical History

Authorization