• PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • RESPONSIBLE PARTY INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • DENTAL INSURANCE INFORMATION

  • Format: (000) 000-0000.
  • Do you have dual coverage?

  • If yes:

  • Format: (000) 000-0000.

  • EMERGENCY INFORMATION

  • Format: (000) 000-0000.

  • I understand that, where appropriate, credit bureau reports may be obtained.

  • MEDICAL HISTORY

  • Date of Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Please choose Yes or No (If Yes, please fill in details)

  • Is the patient taking any medication?
  • Is the patient allergic to any medication?
  • History of a major illness?
  • Has the patient had any operations?
  • Ever been involved in a serious accident?
  • Have seen a physician in the last 12 months? Why?

  • Female Patients only:

  • Is the patient pregnant?
  • Has menstruation started?
  • Check any of the medical conditions below that the patient has had or currently has.

  • DENTAL HISTORY

  • Date of last visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is the patient presently in any dental pain?
  • Ever experienced any unfavorable reaction to dentistry?
  • Has the patient ever lost or chipped any teeth?
  • Have there been any injuries to face, mouth, or teeth?
  • Is any part of your mouth sensitive to temperature? Where?
  • Is any part of your mouth sensitive to pressure? Where?
  • Do gums bleed when brushing?
  • Any type of thumb or tongue habit?
  • Is the patient a mouth breather?
  • Has the patient ever seen an orthodontist? If yes, who and when?
  • Has anyone in the family received orthodontic treatment?
  • Do teeth or jaws ever feel uncomfortable first thing in the morning?
  • Experience jaw clicking or popping?
  • Aware of clenching or grinding teeth during the day?
  • Experience “tension” headaches?
  • Has the patient ever experienced chronic ringing in the ears?
  • Does the patient need extra help with instructions?
  • Is the patient sensitive or self-conscious about his/her teeth?
  • Height of parents?
  • 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 Dr. to perform a complete orthodontic evaluation.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: