Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Address:
City:
State:
Zip:
Email:
Main Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Address:
City:
State:
Zip:
Email:
Main Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:

Dental Insurance Information

Policy Holder's Name:
Policy Holder's Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:

Emergency Contact Information

Nearest relative not living with you:
Name:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Last Dental Visit:
What is the patient's main orthodontic concern?
Has either biological parent ever had orthodontic treatment?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Brush teeth daily?
Floss teeth daily?
Speech problem/therapy?
Grind or clench teeth?
Mouth breathing?
Oral habits(thumb/finger habit, lip/nail biting)?
Snores during sleep?
Injury to face, jaw, teeth, or mouth?
Any missing or extra permanent teeth?
Chipped or injured permanent teeth?
Discomfort from teeth or gums?
Thumb or finger habit as a child?
Pain, tenderness, or noise in either jaw?
Jaw fractures, cysts, mouth infections?
Bleeding gums?
Previous periodontal (gum) treatment?
Other periodontal (gum) problems?
Abnormal swallowing (tongue thrust)?
Frequent canker sores or cold sores?
Teeth that irritate tongue, cheek, lip, etc?
Problems with food trapped between teeth?
History of jaw joint problems?
Experience soreness in the muscles of face or around ears?
Have you been treated for TMJ?
Notice clicking or popping in jaw joint?
Has jaw ever locked?
Do you clench your teeth?
Does bite feel uncomfortable or unusual?
Difficulty chewing or opening mouth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Any changes in patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Anemia or blood disorder?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Bone fractures or trauma to face or jaw?
Diabetes?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Heart valves are damaged or artificial?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Low blood pressure?
Persistent swollen neck glands?
Prolonged bleeding or transfusion?
Prosthetic joints?
Seizures, epilepsy, or neurological disease?
Sexually transmitted disease?
Sinus trouble?
Tonsils enlarged?
Tonsils or adenoids removed?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:

Photo/Video Consent

I give Rollins & Petersen Orthodontics permission to use and publish any photographs or video taken of me or my minor child for educational and promotional purposes. This includes social media, web contact, or online publications. I understand that no royalty or compensation will be awarded to me for such use.
Electronic Signature of Patient/Responsible Party:
Date: