Elko Orthodontic Health History Form

Elko Orthodontic Health History Form

Please fill out this comprehensive health history to help us provide the best orthodontic care.
Patient Information
Patient Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Parent/Guardian Name (if minor)

First NameMiddle NameLast Name
Other family members treated here?
If yes, names of other family members treated here
Referral Source
Responsible Party / Legal Guardian Information
Responsible Party / Legal Guardian Name

First NameMiddle NameLast Name
Marital Status
Residence Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Length at Address (Years)
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Address (if less than 3 years)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Employer
Occupation
Years Employed
Spouse Name

First NameMiddle NameLast Name
Spouse Relationship to Patient
Spouse Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Primary Policy Holder Name

First NameMiddle NameLast Name
Primary ID Number
Insurance Company
Insurance Company Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dual Coverage
Secondary Policy Holder Name

First NameMiddle NameLast Name
Secondary ID Number
Secondary Insurance Company
Secondary Insurance Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Secondary Insurance Phone
Please enter a valid phone number.Format: (000) 000-0000.
Deductible
Emergency Information
Emergency Contact Name

First NameMiddle NameLast Name
Relationship
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Dentist Information
Dentist Name

First NameLast Name
Date of Last Cleaning

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dentist's Main Concern
Health History
Physician Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Currently Under Physician Care?
If yes, please explain
Current Medications
Medication Allergies / Reactions
Previous Orthodontic Consultation?
Orthodontic Provider Name
Prior Orthodontic Treatment?
Medical / Dental Checklist
Check any conditions that apply.
Please explain any checked items
Oral / Orthodontic Conditions
Check any conditions that apply.
Other oral health concerns
Consent and Authorization
Authorization Acknowledgment
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Elko Orthodontic Health History Form

Patient Information

Responsible Party / Legal Guardian Information

Insurance Information

Emergency Information

Dentist Information

Health History

Medical / Dental Checklist

Oral / Orthodontic Conditions

Consent and Authorization