bracesbyfreedmanhaas.com - Patients Under 18 Information Form

Patients Under 18 Information Form
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nickname
DOB

MonthDayYear
Date
Social Security No.
School
Sports/Hobbies
Parent/Guardian Name

First NameLast Name
Whom may we thank for referring you to our office?
Responsible Party Information
Name

First NameLast Name
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone/Other
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security No.
DOB

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
No. of Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
No. of Years Employed
Social Security No.
DOB

MonthDayYear
Date
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Information
Insured's Name

First NameLast Name
Insured's Social Security No.
Insurance Company
Group No.
Local No.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual coverage?
Insured's Name
Insured's Social Security No.
Insurance Company
Group No.
Local No.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Name of Nearest Relative Not Living With You
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that, where appropriate, credit bureau reports may be obtained.
Signature
Date

MonthDayYear
Date
Medical History
Physician
Date of Last Visit

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is the patient taking any medication?
Please describe:
Is the patient allergic to any medication?
Please describe:
Does the patient have a history of a major illness?
Please describe:
Has the patient had any major medical operations?
Please describe:
Has the patient ever been involved in a serious accident?
Please describe:
Have you seen a physician in the last 12 months?
Please describe:
Female Patients Only: Are you pregnant?
Please describe:
Has menstruation begun?
Please check any of the following medical conditions that you have had or currently have.
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?
Is the patient presently in any dental pain?
Please describe:
Has the patient ever experienced any unfavorable reaction to dentistry?
Please describe:
Has the patient had their wisdom teeth removed?
Please describe:
Has the patient ever lost or chipped any teeth?
Please describe:
Have there been any injuries to the patient's face, mouth, or teeth?
Please describe:
Is any part of the patient's mouth sensitive to temperature?
Please describe:
Is any part of the patient's mouth sensitive to pressure?
Please describe:
Does the patient's gums bleed when you brush?
Please describe:
Does the patient have any type of thumb or tongue habit?
Please describe:
Is the patient a mouth breather?
Please describe:
Has the patient ever seen an orthodontist?
If yes, who and when?
What is the patient's attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?
How did they feel about the result?
Does the patient's teeth or jaws ever feel uncomfortable when they awake in the morning?
Please describe:
Is the patient aware of their jaw clicking or popping?
Please describe:
Is the patient aware of clenching their teeth during the day?
Please describe:
Has the patient ever been told that they grind their teeth?
Please describe:
Does the patient experience "tension" headaches?
Please describe:
Has the patient ever experienced chronic ringing in their ears?
Please describe:
Does the patient need extra help with instructions?
Is the patient sensitive or self-conscious about their teeth?
Height of Parents
Mom: Height
Dad: Height
Are you aware that some appointments will be during school hours?
Benefits

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize the doctors to perform a complete orthodontic evaluation.
Signature
Date

MonthDayYear
Date
Should be Empty:

Patients Under 18 Information Form

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Dental History