Patient Information
Today's Date:
/
Month
/
Day
Year
Date
E mail Address:
First Name
Last Name
Middle Initial
I prefer to be called:
Birthdate
Preferred Pronouns
He/Him/His
She/ Her/ Hers
Other
MaritL Status
Single
Married
Divorced
Widowed
Separated
Social Security Number
Home Street Address:
City
State
Zip Code
Home Phone Number
Mobile Number
Work Number
Extension
Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long there?
Occupation:
Where & when are best times to reach you?
How did you hear about us?
Please Select
Word-of-Mouth Referral
Yelp
Online Search
Facebook
Other family members seen by us:
Relation:
Previous Dentist:
Person Responsible for Account:
Are you insured
Yes
No
Spouse/Relative Information
His/ Her Name
First Name
Last Name
Employer:
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Ext:
SS #:
Birthdate:
/
Month
/
Day
Year
Date
DL #:
Relative or Friend not Living with you:
His/Her Name
Relation
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Orthodontic Insurance Information
Primary Insurance
Orthodontic Coverage
Yes
No
Dental Coverage?
Yes
No
Insurance Coverage Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
Group Plan or Policy Number
Insured's Name
Relationship to Insured
Insured's Birthdate
Insured's Social Security
Insured's Employer:
Employer's Address
Street Address
Street Address Line 2
City
Please Select
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District of Columbia
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Secondary Insurance
Orthodontic Coverage
Yes
No
Orthodontic Coverage
Yes
No
Insured Co. Name
Insured Co. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Insured's Name:
Insured's Birthdate:
/
Month
/
Day
Year
Date
Insured's SS #:
Insured's Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Payment Agreement
Payment is due in full at the time of treatment unless prior arrangements have been approved. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authroize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature
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Medical History
Do you have a personal physician
Yes
No
Physician's Name:
Physician's Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last visit:
/
Month
/
Day
Year
Date
Your current physical health is:
Good
Fair
Poor
Are your currently under the care of a physician?
Yes
No
Please explain:
Do you smoke or use any tobacco in any form?
Yes
No
Have you had any metal rods, pins or implants?
Yes
No
Are you taking any prescription/ over-the-counter drugs?
Yes
No
Please list any drugs you are taking:
Have you ever taken Phen-Fen? Also known as Redux or Pondimin.
Yes
No
If so, when?
For Women:
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
If you are pregnant, what week are you in?
If you are pregnant, are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Abnormal bleeding/ Hemophilia
Yes
No
AIDS
Yes
No
Alcohol/ Drug Abuse
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Artificial Bones/ Joints/ Valves
Yes
No
Asthma
Yes
No
Blood Transfusion
Yes
No
Cancer/ Chemotherapy
Yes
No
Colitis
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fainting Spells
Yes
No
Frequent Heartaches
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack/ Surgery
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes / Fever Blisters
Yes
No
High Blood Pressure
Yes
No
HIV
Yes
No
Hospitalized for any Reason
Yes
No
Kidney Problems
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lupus
Yes
No
Mitral Valve Prolapse
Yes
No
Pacemaker
Yes
No
Psychiatric Problems
Yes
No
Radiation Treatment
Yes
No
Rheumatic/ Scarlet Fever
Yes
No
Seizures
Yes
No
Shingles
Yes
No
Sickle Cell Disease/ Traits
Yes
No
Sinus Problems
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tuberculosis (TB)
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Jewelry/ Metals
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Tetracycline
Yes
No
Other
Yes
No
Please list any other drugs/ materials that you are allergic to:
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Dental History
What are the main concerns that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joint (TMJ/TMD)?
Yes
No
Your current health is
Good
Fair
Poor
Do you still have wisdom teeth?
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any speech problems?
Do you generally breathe through your mouth?
Yes
No
If yes, please indicate:
While awake?
While asleep?
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any missing or extra permanent teeth?
Yes
No
Are you happy with the way your smile looks?
Yes
No
If not, what would you change?
Acknowledgement
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services
Signature
Date:
/
Month
/
Day
Year
Date
Submit
Should be Empty: