Mizrahi

Patient
Appointment Date/Time

MonthDayYear
Date
First
Last
Nickname
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Age
Social Security
School
Grade
Email
example@example.com
Hobbies/Interests
If patient is a minor give parents or guardians name
Do you have legal custody of this child?

YesNo
List brothers/sisters & ages
How did you hear about our office?
Friends or family treated by Dr Mizrahi
RESPONSIBLE PARTY INFORMATION
First
Last
Marital Status
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
How long at this address?
Social Security
Birthdate

MonthDayYear
Date
Relationship to Patient
Email
example@example.com
Employer
Occupation
No. Years Employed
Spouse's name
Relationship to Patient
Employer
Occupation
No. Years Employed
Social Security
Birthdate

MonthDayYear
Date
Work Phone
Format: (000) 000-0000.
INSURANCE INFORMATION
Orthodontic Coverage

YesNoDon't Know
Primary Insurer
If yes, Insureds Name
Social Security
Birthdate

MonthDayYear
Date
Insurance Company
Group No
Plan
Insurance Co Address
Insurance Co. Phone
Format: (000) 000-0000.
Do you have dual coverage?

YesNo
Secondary Insurer
If yes, Insureds Name
Social Security
Birthdate

MonthDayYear
Date
Insurance Company
Group No
Plan
Insurance Co Address
Insurance Co. Phone
Format: (000) 000-0000.
Emergency Information
Name of nearest friend relative not living with you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
MEDICAL HISTORY
Physician
Date of last visit

MonthDayYear
Date
Current physical health?

GoodFairPoor
Are you taking any medications?

YesNo
List
Are you allergic to any medications?

YesNo
List
Have you had any serious injury to head or neck?

YesNo
Describe
Have tonsils or adenoids been removed?

YesNo
When
If patient is a minor, has puberty begun?

YesNo
Age
Check any medical conditions you have had or are currently being treated for:
Check any medical conditions you have had or are currently being treated for:

AIDS/HIV+Blood DisordersEndocrine ProblemsHemophiliaRheumatic FeverAnemiaBone DisordersEpilepsy/ConvulsionsHepatitisSinus ProblemsArthritisDiabetesHandicaps/DisabilitiesHerpesThyroidAsthma or Hay FeverDizziness/FaintingHeart DefectsHigh Blood PressureTuberculosisAllergy to Latex/MetalEmotional ProblemsHeart MurmurMigrainesTumor or Cancer
List any other medical condition or problem:
Do you need to be premedicated prior to dental procedure

YesNo
If so, state medication and reason
Dental History
Dentist
Last Visit
Have there been any injuries to the face, mouth, teeth or chin?

YesNo
Do you have any missing or extra permanent teeth?

YesNo
Do your gums routinely bleed when you brush?

YesNo
Do you have any speech problems?

YesNo
Do you have a thumb, finger or tongue thrust problem?

YesNo
Do you breathe through your mouth, or are your lips often parted?

YesNo
Have you ever had any orthodontic treatment?

YesNo
When?
Has anyone in the family received orthodontic treatment?

YesNo
When?
Who?
Do you have any pain or soreness around your eyes, neck or back?

YesNo
If so, which side?

LeftRightBoth
How frequent?

ConstantPeriodic
Do you feel you clench or grind your teeth during the day or at night?

YesNo
Are you aware of your jaw joints clicking, popping or locking?

YesNo
If so, which side?

LeftRightBoth
How frequent?

ConstantPeriodic
Are you aware that orthodontic appointments will infringe on some school or work time?

YesNo
What would you like orthodontics to accomplish?
I understand the information I have given is correct to the best of my knowledge, and it will be held in the strictest of confidence by this office. It is my responsibility to inform the dental staff of any changes in the medical status. I authorize the doctor to perform any necessary dental services with my informed consent that may be needed during diagnosis and treatment. I also understand that this office reserves the right to verify the credit status of potential patients and /or parents of patients prior to extending credit for treatment fees. I acknowledge receipt of this office's notice of Privacy Practices.
Signature of Patient/Parent or Guardian
Date

MonthDayYear
Date
Should be Empty:

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

Emergency Information

MEDICAL HISTORY

Dental History