Confidential Patient Information

First Name:
Last Name:
Nickname:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Birthdate:
Age:
Sex:
School:
If patient under 18, list names & ages of other children in family:
Patient's Dentist:
Who Referred You?
 
 

Responsible Party

First Name:
Last Name:
Marital Status:
Address:
City:
State:
Zip:
Relationship to Patient:
Birthdate:
Employer:
Work Phone:
Occupation:
No yrs. Employed:
Spouse's Name:
Spouse's Employer:
Occupation:
Work Phone:

Dental Insurance Information

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

Emergency Information

Name of nearest relative not living with you:
Phone:
What is your main concern about your teeth?
Have you ever seen an orthodontist?
When
Whom

Medical History

Has Patient Been under the care of a physician within the past 2 yrs.?
Does the patient have a history of any of the following?
List any other serious illnesses or operations not mentioned above:
List any drugs or medications presently being taken:
List any allergies or drug sensitivites:

Dental History

Do you have any pain or Clicking of your jaw joints?
Does Your jaw ever lock after opening your mouth?
Do you clench or grind your teeth?
Have there been any injuries to the mouth, teeth or jaw?
When were your last dental X-Rays?
When was your Last Dental Cleaning?
List anything else you think the doctor should know:
Signature (Parent's signature if minor):