Submit Your Health History Form Online to Showtime Orthodontics

Submit Your Health History Form Online to Showtime Orthodontics

Save time at our office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You will need to provide a signature at the office to verify that the information you submitted online is accurate. We look forward to meeting you!
Patient Information
Patient Name*

First NameLast Name
Gender*

MaleFemale
Date Of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party Information
Responsible Party Name*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address (if is different than patient home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our office?*
Dental Insurance Information
Do you have dental insurance?*

YesNo
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's Social Security Number (U.S. only)
Insurance Company Name
Insurance ID Number
Group Number
Insurance Phone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have dual insurance coverage?*

YesNo
If you have dual insurance coverage, Please list 2nd insurance information here:
Emergency Information
Name of the nearest relative not living with you
Phone
Please enter a valid phone number.
Dental History

Dental Questionnaire

	Yes	No
Do you get food caught between your teeth?
Do you have any missing teeth?
Do your gums bleed?
Do you have areas of receded gums?
Do you floss regularly?
Does gum disease run in your family?
Are your teeth hot/cold sensitive?
Teeth extracted?
Are your teeth sensitive to sweets?
Do you clench or grind your teeth?
Do you have a night guard/bite splint?
Have you ever had an oral surgery?
Do you have tired jaws?
Do you have orthodontics/braces?
Do you have popping or clicking in the jaw?
Have you ever had a periodontal treatment?
Do you chew on pens, fingernails, etc?
Have you had any injury to your face/jaw?
Do you drink coffee, tea or red wine?

General Dentist
Last Visit

MonthDayYear
Date
Have you ever had orthodontics treatment before?*
What concerns you most about your teeth?
If an appointment slot opens up, would you be interested in starting treatment the same day?
Medical History

Medical Questionnaire

	Yes	No
Heart surgery, disease, attack?
Blood transfusion?
Heart murmur?
Hemophilia or blood disorder?
Mitral valve prolapse?
Hepatitis A, B?
Heart attack or strokes?
Tuberculosis or lung disease?
Artificial heart valve?
Tumors?
Heart pacemaker?
Headaches or migraines?
Artificial joints (hip, knee, etc)?
Convulsions or epilepsy?
Neurological disorders?
Dizzy spells or fainting?
Rheumatic fever?
Cold sores or fever blisters?
Diabetes?
Thyroid disorder?
Kidney disease?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Psychiatric or psychological care?
Cancer?
Hay fever or airborne allergies?
Radiation or Chemotherapy?
Bruise easily?
Emphysema or asthma?
Venereal disease?

Are you allergic to any medication?*
Do you have any other disease/condition not listed above?
Do you use recreational drugs?

YesNo
How often do you consume alcoholic beverages?

NeverOnce a month2-3 times a weekOnce a weekEveryday
Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration
Are you currently pregnant or trying to become pregnant?

YesNo
Are you currently use a prescription type contraceptive? Please explain
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.Signature*Date*
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Submit Your Health History Form Online to Showtime Orthodontics

Patient Information

Responsible Party Information

Dental Insurance Information

Emergency Information

Dental History

Medical History