Form

1
Is this for you or for your child?* This field is required
For me
For my child
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2
Patient Full Name* This field is required
First Name
Last Name
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3
Mobile Phone Number* This field is requiredCell Phone # of person responsible
Area Code
Phone Number
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4
Your Child's Mobile PhoneOnly for text appointment reminders if your child drives themselves
Area Code
Phone Number
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5
Your birthdate* This field is required
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6
Your Child's birthdate* This field is required
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7
What is your gender?* This field is required
Male
Female
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8
What is your child's gender?* This field is required
Male
Female
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9
Address* This field is required
Street Address
Street Address Line 2
City
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Alabama
Alaska
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District of Columbia
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New York
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Ohio
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Oregon
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Texas
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Virginia
Washington
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Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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10
Email* This field is required
example@example.com
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11
Whom may we thank for referring you?* This field is requiredSomeone? Google? Facebook? Walk-by? Other?
Please write in their name if it is a person who referred you
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12
Check the conditions that apply to you :* This field is requiredScroll down for more options
No Medical Problems, I'm healthy
Asthma
Diabetes
Hypertension/High Blood Pressure
Heart disease/Heart Attack/Sroke
Artificial Joints/Valves
Heart Murmur
Congenital Heart Defect/Heart Surgery/Pacemaker
Psychiatric disorder
Epilepsy/Seizure/Fainting
Cancer/Chemotherapy/Radiation Therapy
Hepatitis
HIV/AIDS
Kidney Problems
Sinus Problems
Arthritis
Abnormal bleeding
Ever had injury to mouth, teeth or chin
Hearing impairment
I may need Antibiotic Premedication prior to invasive dental treatments
Autism
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13
Check the conditions that apply to your child :* This field is requiredScroll down for more options
No Medical Problems, I'm healthy
Asthma
Diabetes
Hypertension/High Blood Pressure
Heart disease/Heart Attack/Sroke
Artificial Joints/Valves
Heart Murmur
Congenital Heart Defect/Heart Surgery/Pacemaker
Psychiatric disorder
Epilepsy/Seizure/Fainting
Cancer/Chemotherapy/Radiation Therapy
Hepatitis
HIV/AIDS
Kidney Problems
Sinus Problems
Arthritis
Abnormal bleeding
Ever had injury to mouth, teeth or chin
Hearing impairment
I may need Antibiotic Premedication prior to invasive dental treatments
Autism
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14
Are you currently taking any medication?* This field is required
Yes
No
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15
Is your child currently taking any medication?* This field is required
Yes
No
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16
What medications are you (or your child) taking?Please list medications below. Skip if none.
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17
Mother's information* This field is required(or legal guardian. Type "na" if not available)
Mother's name
Mother's Mobile phone #
Mother's date of birth
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18
Father's information* This field is required(or legal guardian. Type "na" if not available)
Father's name
Father's Mobile phone #
Father's date of birth
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19
Do you have any allergies?* This field is requiredScroll down for more options
No I'm not allergic to anything
Aspirin
Codeine
Tetracycline
Dental Anesthetics
Metal
Erythromycin
Penicillin
Amoxicillin
Latex
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20
Does your child have any allergies?* This field is requiredScroll down for more options
No I'm not allergic to anything
Aspirin
Codeine
Tetracycline
Dental Anesthetics
Metal
Erythromycin
Penicillin
Amoxicillin
Latex
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21
Do you use tobacco products?* This field is requiredCigarettes, cigars, chewing tobacco etc.
YESNO
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22
Does your child use tobacco products?* This field is requiredCigarettes, cigars, chewing tobacco etc.
YESNO
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23
Do you have jaw joint (TMJ) problem?* This field is requiredScroll down for more options
No TMJ issues
Clicking
Popping
Lock jaw
Pain
I grind my teeth
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24
Does your child have jaw joint (TMJ) problem?* This field is requiredScroll down for more options
No TMJ issues that I know of
Clicking
Popping
Lock jaw
Pain
I grind my teeth
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25
Who is your general dentist?Type "none" if you don't have one
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26
Who is your child's general dentist?Type "none" if you don't have one
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27
Who is your employer?* This field is required
You can also use: None, Student, Self-employed etc.
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28
Do you have Orthodontic Insurance?* This field is required
YESNO
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29
Insurance information (front picture of card)For your convenience take a photo of the FRONT of your insurance card (Optional):
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30
Insurance information (back picture of card)Take photo of the BACK of your insurance card (Optional):
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31
Are you the policyholder?* This field is required
YESNO
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32
Insurance company information (Self)We can estimate your coverage if you provide the following information about your insurance company:
Ins Name
Ins Address
Ins Phone #
Group #
Policy/ins #
Your SS# or ID#
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33
Insurance company information (Policyholder)We can estimate your coverage if you provide the following information about your insurance company:
Ins Name
Ins Address
Ins Phone #
Group #
Policy/insurance #
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34
Policyholder information We can estimate your coverage if you provide the following information about the Policyholder:
Name
Birthdate
Employer
SS# or ID#
Relationship of policyholder to patient
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35
Emergency contactIn an urgent situation, is there someone who lives near you that we should contact?
Name
Relationship
Please enter phone # for emergency contact
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36
What is your main orthodontic concern?What would you like Dr Leo to address?
Small
Normal
Large
Huge
Ok
Ok
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37
Privacy Notice Acknowledgement* This field is requiredPlease click on the link below to read how we protect your private information.
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38
SignatureThe information, health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental/orthodontic services agreed between doctor and patient to be necessary or advisable. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered (i.e. I understand that if my insurance stopped paying, I will be responsible to pay what the insurance was supposed to pay for). If I ever have any changes in my health or if my medication changes I will, without fail, inform the doctor at my next appointment.
Clear
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39
Your name* This field is requiredName of person filling this form out
First Name
Last Name
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40
Date* This field is required
Date
Year
Month
Day
Date
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Should be Empty: