Confidential Patient Information

Today's Date:
First Name:
Middle Initial:
Last Name:
Preferred Name:


Birthdate:
Age:
Grade:
School Attends:
Home Phone:
Cell Phone:
Address:
City:
State:
Zip:
Name/Relationship of person accompanying patient to today's appointment:
Who has legal custody of patient?
Name of siblings & ages:
Have we treated any family members? If yes, who?
Whom may we thank for referring you?

Responsible Party

Marital Status:
Mother's Name:
Relationship to Patient:
Date of Birth:
SSN:
Address:
City:
State:
Zip:
How long at this address?
Cell Phone:
Work Phone:
Employer:
Years employed:
Occupation:
Email:
Father's Name:
Relationship to Patient:
Date of Birth:
SSN:
Address:
City:
State:
Zip:
How long at this address?
Cell Phone:
Work Phone:
Employer:
Years employed:
Occupation:
Email:

Primary Dental Insurance Information

Insurance Company:
Insurance Phone Number:
Employer/Group Name:
Group Number:
Subscriber/Employee:
Subscriber ID/SSN:
Date of Birth:
Relationship to Patient:

Secondary Dental Insurance Information

Insurance Company:
Insurance Phone Number:
Employer/Group Name:
Group Number:
Subscriber/Employee:
Subscriber ID/SSN:
Date of Birth:
Relationship to Patient:

Emergency Contact Information

Name:
Relationship to Patient:
Home Phone:
Cell Phone:

Medical History

PLEASE READ: We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.
Physician:
Phone:
Date of Last Exam:
1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operations or serious illness in the past five years?
3. Are you taking medications including non-prescription medicine?
If yes, what medications are you taking?
4. Do you use tobacco?
5. Are you aware of being allergic to any medications or substance, including metals?
If yes, what?
6. Females Only: Are you pregnant, or think you may be?
A. Has menstruation begun?
If yes, date:
B. Females Only: Are you pregnant, or think you may be?
7. Ever taken Bisphosphonates (ex: Fosomax) for Osteoporosis?
IF yes, specify:
8. Has the patient reached puberty?
9. Please check all that apply:
If so, specify:

Dental History

Dentist:
Date of Last Cleaning:
1. Are you anxious or nervous about dental treatment?
2. Do you require premedication for dental treatment?
3. Do you feel pain to any of your teeth?
4. Do you have any sores or lumps in or near your mouth?
5. Have you had any head, neck, or jaw injuries?
If yes, please describe:
6. Do you have any ongoing problems in your jaw with:
A. Chronic clicking or popping?
B. Pain
C. Difficulty opening or closing?
D. Difficulty in chewing?
7. Do you clench or grind your teeth?
8. Do you bite your lips or cheeks frequently?
9. Have you ever had speech therapy?
If yes, please describe:
10. Is there any outstanding dental treatment to be completed?
If yes, please describe:
11. Have you ever had instruction on the correct method of brushing and flossing your teeth?
12. Do you have any of the following oral habits:
A. Nail biting?
B. Thumb sucking?
C. Tongue thrust while swallowing?
D. Mouth breathing?
13. How many times a day do you brush?
14. Please check the boxes below which describe the problem(s) for which you are seeking treatment:
15. Has the patient had an orthodontic evaluation or treatment before?
If so, when and by whom?

Authorization and Release

To the best of my knowledge the above questions have been accurately answered and it is my responsibility to inform this office of any changes to the patient's medical status. I give Robison Orthodontics permission to perform an orthodontic examination and evaluation by signing this form. I consent to allow Robison Orthodontics to use my records anonymously for educational and promotional purposes.

Please list who we can share information with:
Signature of Patient:
Date:

Release

I hereby give permission for Stanley J Robison, DDS, MS, PA to photograph and radiograph (x-ray) my face and jaws for diagnostic and follow-up evaluation purposes. It is my understanding that all or portions of the study materials will be examined and analyzed in order to provide the best possible treatment and that all or portions of the material may be used for presentation as educational information. In doing so, Stanley J Robison, DDS, MS, PA agrees to take appropriate measures to insure the privacy of the patient.
Patient Name:
Signature of Patient or Parent/Guardian:
Date: