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:
*
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/patient would like orthodontics to correct?:
*
Has patient had other orthodontic treatment?
Yes
No
Orthodontist Name:
Does patient have any of the following oral issues? (Select all that apply):
*
high decay rate
malformed teeth
missing teeth
extra teeth
poor oral hygeine
neglect of gums
"white spots" on teeth
gag reflex
none of the above
Other oral issues:
How frequently does patient brush his/her teeth?
Do patient's gums bleed with brushing?
Yes
No
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
none of the above
Has the patient ever had an injury to the mouth? (Select all that apply):
teeth
mouth
chin
If so: What was the cause of the accident? How old was the patient at time of injury? Which teeth were involved?
Has patient had any history of speech problems or speech therapy?
Yes
No
Does patient have any of the following habits? (Select all that apply):
*
clenching/grinding teeth
lip sucking/biting
constant mouth breathing
nail biting
thumb/finger sucking
tongue thrusting
none of the above
Has patient ever experienced any sleep-related breathing disorders?
mouth breathing
snoring
trouble breathing during sleep
Has patient ever had periodontal (gum) surgery?
Yes
No
Has patient ever had oral surgery?
Yes
No
Has patient had any unfavorable experiences in a dental office or has dental anxiety?
Yes
No
If yes, please explain:
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Medical History
Patient's Physician Name:
Does patient have a current medical condition?
*
Yes
No
If yes, please explain:
Is patient taking any medications, nutritional supplements or herbal medications at this time? Please list below
*
Yes
No
Medication, dosage, taken for:
Medication, dosage, taken for:
Medication, dosage, taken for:
Has patient ever taken medications for bone disorders or cancer such as bisphosphonates such as Fosamax, Actonel, or Boniva?
*
Yes
No
Has the patient had allergies or reactions to any of the following? (check all that apply):
*
Latex
Aspirin
Ibuprofen
Penicillin
Local Anesthetics
Metals
Acrylics
Other
None of the above
If other, please list:
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:
*
Emotional, sensory or developmental issues
Autism Spectrum Disorder (ASD)
Skin disorder (other than common acne)
Epilepsy, seizures
Diabetes
Endocrine, thyroid issues
Kidney disease
Asthma, sinus problems
Major surgery
Liver disease, Hepatitis
Tumor, Cancer
History of eating disorder
Serious accident
Heart problems, murmur
Autoimmune disorder
Arthritis, joint problems
History of osteoporosis
Frequent ear infections, colds, throat infections
Frequent headaches or migraines
Vision, hearing, or speech problems
Herpes, STD
AIDS, HIV
Removal of adenoids or tonsils
None of the above
Any other conditions not mentioned above:
Is patient pregnant now?
Yes
No
Does patient smoke, vape, or use tobacco in any form?
Yes
No
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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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