Patient Information
Patient Full Name:
*
First Name
Last Name
Preferred Name:
Gender
*
Male
Female
Identifies as
Male
Female
Non-Binary
Birth Date:
*
Home Address:
*
City:
*
State:
*
Zip:
*
Primary Phone Number:
*
Phone Type
home
cell
E-mail:
*
School:
Grade:
List any sports or extracurricular activities:
Siblings (names and ages):
How would you like to receive appointment reminders?
email
text
If text, please enter text number:
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Parent/Guardian Information
Parent 1
Parent 1 Name:
Marital status
Single
Married
Divorced
Widowed
Partner
Relation to patient
Mother
Father
Step-mother
Step-father
Guardian
Other
Address (if different than child's):
City:
State:
Zip:
Primary Phone:
Phone Type
home
cell
E-mail:
Parent 2
Parent 2 Name:
Marital status
Single
Married
Divorced
Widowed
Partner
Relation to patient
Mother
Father
Step-mother
Step-father
Guardian
Other
Address (if different than child's):
City:
State:
Zip:
Primary Phone:
Phone type
home
cell
E-mail:
Emergency Contact Information
Emergency Contact Name (other than parent):
Phone Number:
Who has authorization to allow medical treatment for patient?
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Dental Insurance Information
Primary Dental Insurance
Primary Insurance Company:
Phone Number:
Group Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:
Employer:
Secondary Dental Insurance
Secondary Insurance Company:
Phone Number:
Group Number:
Member ID Number:
Policy Holder's Name:
Relation to Patient:
Policy Holder's SSN:
Policy Holder's Date of Birth:
Employer:
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Dental History
General Dentist Name:
*
Last Visit:
How did you hear about our practice?
Ad
Internet
Family/friend
Dentist
Other
Name of person referring (if applicable):
What are the main concerns you would like orthodontics to correct?
*
Has the patient visited an orthodontist before?
Yes
No
If yes, when?:
Orthodontist Name:
Have we treated any other family members?
Yes
No
Name(s):
Has the patient's tonsils or adenoids been removed?
*
Yes
No
Does patient have any of the following oral problems? (Select all that apply):
high decay rate
malformed teeth
missing teeth
extra teeth
poor oral hygeine
neglect of gums
"white spots" on teeth
Does patient have any jaw problems? (Select all that apply):
clicking of jaw
jaw pain
difficulty in chewing
clenching/grinding teeth
stiff jaw on awakening
jaw stuck open/closed
difficulty opening/closing
Other oral problems:
Has the patient ever had an injury to the mouth? (Select all that apply):
teeth
mouth
chin
Does the patient have speech problems?
Yes
No
If so, explain:
Does patient have any of the following habits? (Select all that apply):
clenching/grinding teeth
lip sucking/biting
mouth breathing
nail biting
thumb/finger sucking
tongue thrusting
chewing/eating problem
snoring/sleep apnea
Has patient ever had peridontal surgery?
Yes
No
If yes, please provide details:
Has patient ever had oral surgery?
Yes
No
If yes, please provide details:
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Medical History
Is the patient currently being treated by a physician?
Yes
No
Reason:
Physician Name:
Last Visit:
Does the patient have a current medical condition?
*
Yes
No
If yes, please explain:
Is the patient currently taking any medications?
*
Yes
No
If yes, please list type and dosage:
Is the patient adopted?
Yes
No
If yes, does the patient know?
Yes
No
Check if the patient has or ever had any of the following:
hearing difficulties
asthma
emotional difficulties
fainting or dizziness
poor vision
liver disease or hepatitis
diabetes
blood problems
bone/joint problems
kidney disease
heart problems, murmer
autoimmune disorder
frequent headaches
arthiritis
skin problems
epilepsy or seizures
cerebral palsy
sinus problems
breathing problems
birth defects
herpes virus
tumor, cancer
blood transfusion
major surgery
serious accident
stomach problems
head or neck pain
ulcers
Any other condition not mentioned above:
Has the patient had allergies or reactions to any of the following drugs?(check all that apply):
*
Aspirin
Codeine
Erythromycin
Ibuprofen
Local Anesthetics
Penicillin
Latex
Other
None of the Above
if other, please list:
Does patient have a history of allergies?
Yes
No
If yes, please explain:
Has patient had any unfavorable experiences in a dental or medical office?
Yes
No
If yes, please describe:
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Authorization
I understand that the information that I have given is correct to the best of my knowledge, and that it will be held in the strictest confidence. I understand it is my responsibility to inform this office of any changes in the patient's medical/dental status. I authorize the orthodontic staff to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's dental needs.The office reserves the right to conduct a Credit Check. I understand I am financially responsible whether my insurance company pays or not, for all charges incurred. I further agree that in the event of nonpayment, I will bear the cost of collection and/or court costs and reasonable legal fees should such action be required.
Signature
Date:
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