VARGAS ORTHODONTICS

VARGAS ORTHODONTICS
Patients Name
DOB
Gender
Social security number
Phone Number
Please enter a valid phone number.
Cell Phone Carrier
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
School
Whom may we thank for referring you to us?
Responsible Party
Name
DOB
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address: (if different):

Mailing Address if different

Street Address Line 2

CityState

Postal / Zip Code
Employer
Occupation
SSN
Spouses Name
Email Address
example@example.com
Birthdate

MonthDayYear
Date
Cell Number
Please enter a valid phone number.
Cell Carrier
Employer
INSURANCE INFORMATION
Insureds Name
Insurance Co
Dental Policy Number
Insurance CO Address
Phone Number
Please enter a valid phone number.
Group Number
Insurance CO Address
Do you have dual coverage?

YesNo
Insureds Name
Insurance Co
Dental Policy Number
Insurance CO Address
Phone Number
Please enter a valid phone number.
Group Number
Insurance CO Address
Are you planning on using a Flex Spending or Health savings towards orthodontic treatment?

YesNo
MEDICAL/DENTAL HISTORY
Physicians Name
Phone
Dentists Name
Phone
Date of last cleaning

MonthDayYear
Date

Type a question

Rows	Yes	No
Are you currently under any medical treatment?
Do you have pain, clicking, and/or popping noises in the jaw?
Are you aware of either clenching or grinding of teeth?
Do you have frequent headaches? How often?
Do you have ear problems? (Aches, ringing, dizziness, fullness)
Do you have difficulty breathing through the nose?
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
Do you have speech problems, or are you in speech therapy?
Have you had your tonsils and/or adenoids removed?
Has there been any history of: Joint swelling Asthma Epilepsy Rheumatic fever Other major illnesses?
Do you bleed easily?
Do you have allergies? (Sulphur, penicillin, Novocain, etc )
Are you currently taking any medication?
Do you have a heart condition?
Do you pre-medicate?Do you have sleep apnea?
Do you smoke or chew tobacco?
Have there been any injuries to the teeth?
Have you had any permanent teeth extracted?
Do you have sleep apnea?

Responsible Party