Confidential Patient Information

First Name:
Last Name:
Main Phone:
2nd/Cell Phone:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security # (for insurance verification):

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Social Security # (for insurance verification):
Length of Employment:
Work Phone #:

Dental Insurance Information

Do you have dental insurance?
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Phone No.:

Emergency Information

Best Phone:
Relationship to Patient:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Chipped or injured permanent teeth?
Previous root canal therapy?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

Has there been any change in the 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?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Metal Allergy
List any drug allergies or sensitivities (not listed above) 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. Cannot be blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
Tonsils/Adenoids Removed
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Growth Problems
Tuberculosis or Lung Disease
Received Radiation Treatment
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Respiratory problems / Emphysema
Sexually transmitted disease
Low blood pressure
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.
Click here to read the HIPAA Consent Policy.

Authorization for Cell Phone and Email Use

I give my consent to the orthodontic practice to use my cell phone for appointment, treatment information, insurance and billing information. I understand that I can withdraw my consent at any time.
Choose one:
I give my consent to receive email communications regarding treatment information, insurance, account and billing information, and special promotions from the orthodontic practice. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I understand that I can withdraw my consent at any time.

Photographic/Media/Social Media Consent

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Honey Orthodontics to use my image, video and photographic likeness and/or any interview statements from me in its office, publications, advertising or ortho media activities (including the Internet and social media sites) for the purpose of informing patients of the positive outcome we have achieved.

I understand that no personal information, such as full names, will be used in any publications unless express consent is given.

I also understand that my consent can be withdrawn at anytime in writing to Honey Orthodontics.

I have read the above statements and I give this consent voluntarily.