Blue denotes a required field
Date of Birth:
Date of Birth
Spouse/Additional Contact Information
Dental Insurance Information
Policy Holder's Information
Insurance Company's Information
Do you have dual insurance coverage?
2nd Policy Holder's Information
Has your child ever had any orthodontics treatment?
Have you ever had orthodontic treatment?
Are you under the care of a physician?
Is the child currently under the care of a physician?
Date of Last Visit
Has puberty begun?
Has menstruation (period) begun?
Are you pregnant?
When and for what have you been hospitalized?
When and for what has your child been hospitalized?
Have adenoids or tonsils been removed?
Do you now or have you ever experienced pain/discomfort in your jaw joint(TMJ/TMD)?
Has the patient ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Do you have any speech problems?
Does the patient have speech problems?
Do you have any congenitally missing or extra permanant teeth?
Does the patient have any congenitally missing or extra permanant teeth?
Have you ever had an injury to:
(select all that apply)
Has the patient ever had an injury to:
Do your gums ever bleed?
Do you like your smile?
Do you smoke?
Do/Have you ever had any of the following habits?
Does/Has the patient ever had any of the following habits?
Are you allergic to any of the following?
(Check ALL that apply)
Is the child allergic to any of the following?
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medical status.
I hereby authorize the release of any information related to insurance claims. I consent to the examiniation by the doctor and I authorize payment of any insurance benefits to the office. I understand that where appropriate, credit bureau reports may be obtained.