Welcome to Mongiovi Orthodontics

We would like to welcome you to our office. Our goal is to make every visit pleasant and educational. We strive to teach good oral care that will enable you to have a beautiful smile that lasts a lifetime.

Tell us about yourself

Date:
Gender:
First Name:
Middle Initial:
Last Name:
I prefer to be called:
Age:
Date of Birth:
SSN:
Address:
City:
State:
Zip:
Email:
Home #:
Work #:
Cell #:
Marital Status:
Who may we thank for referring you?
Other family members seen by us:

Employer Information

Employer:
Address:
Occupation:
How long there?

Spouse Information

Name:
Date of Birth:
Address (if different from patient's):
Employer:
Title:
Employer Address:
Work #:
Cell #:
How long at current job?
SSN:

In case of an emergency, whom do we contact?

Name:
Relation:
Phone #:

Responsible Party

The Responsible Party for the patient named above is indicated below. I certify that I am the Parent or Legal Guardian of the patient and am authorized to make treatment and financial related decisions on their behalf. I understand that all patients are required to have one Responsible Party that agrees to be fully, financially responsible for the entire Treatment Fee and responsible for any Medical History or Insurance information that may be presented. Patients under 18 years of age are considered minors and cannot be their own Responsible Party. Having one Responsible Party is vital to ensuring that treatment progresses as it should. In order for treatment to begin, the Responsible Party must sign an informed consent and agree to participate in treatment discussions with Dr. Mongiovi, as needed. The Responsible Party should be present at all visits so that they are included in home care instructions, will assist the patient with all at home directions, will ensure that appointments are made and kept as required and will coordinate all communication with any other family member that may be involved, in any way, with the patient’s orthodontic care.
Please designate one person who will take responsibility for scheduling, visits, financial obligations, and insurance coverage, and will also participate in home care instructions.
Name:
Relation:
Address:
Home Phone:
Work Phone:
Cell Phone:
Email:
Appointment reminders and other important information is sent via text and email. Please keep this information updated.

Insurance Information

Primary Insurance
Dental Coverage?
Orthodontic Coverage?
Insurance Co. Name:
Insurance Co. Address:
Phone #:
Group #:
Policy Owner Name:
Date of Birth:
Social Security or Patient ID Number:
Secondary Insurance
Dental Coverage?
Orthodontic Coverage?
Insurance Co. Name:
Insurance Co. Address:
Phone #:
Group #:
Policy Owner Name:
Date of Birth:
Social Security or Patient ID Number:

Medical History

Your General Health:
Name of Physician:
Date of last visit:
Are you currently under the care of a physician?
If yes, please explain:
Are you taking any medications?
If Yes, please list all medications:
Do you have any drug or non-drug allergies?
If Yes, please describe all allergies:
Are you allergic to any of the following?
Metals
Plastics
Latex
Penicillin
Antibiotics
Dental Anesthetics
Other
If you answered "yes" to any of the above, please describe.
Please check Yes (‘Y’) or No (‘N’) whether you have a history of the following:
Abnormal Bleeding
ADD/ADHD
Anemia
Arthritis
Artificial Bones/Joints
Asthma/Diff. Breathing
Autism
Back Problems
Blood Disease
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Diabetes
Drug/Alcohol Abuse
Emphysema
Fainting Spells
Fever Blisters/Herpes
Glaucoma
Handicaps/Disabilities
Heart Attack
Heart Murmur
Heart Surgery/Pacemaker
Hepatitis
High/Low Blood Pressure
HIV+/AIDS
Kidney/Liver Problems
Psychiatric Problem
Rheumatic/Scarlet Fever
Severe/Frequent Headaches
Shingles
Sickle Cell Disease/Trait
Sinus Problems
Thyroid Disease/Malfunc.
Tonsils/Adenoids Removed
Tuberculosis
Venereal Disease
Seizures/Epilepsy
Mitral Valve Prolapse
Ever been hospitalized?
Please provide additional information if you checked YES to any of the above:

Dental History

General Dentist:
Dentist Phone #:
Last visit:
Have you ever been evaluated or had orthodontic treatment before?
Have there been any injuries to the face, mouth, teeth or chin?
Have you been informed of any missing or extra permanent teeth?
Do you have any pain or tenderness in the jaw joint (TMJ/TMD)?
Do you have any speech problems?
Do you currently have a thumb or finger sucking habit?
What are the main concerns you would like orthodontics to accomplish?
I certify that I am the Parent or Legal Guardian of the patient and am authorized to make treatment and financial related decisions on their behalf. I understand that I am responsible for the information that I have provided today and that it is all correct, to the best of my knowledge. I understand that it will be held in the strictest of confidence. I understand that it is my responsibility to inform this office of any changes to the information that has been provided, including but not limited to the patient’s insurance related information or medical status. A copy of the office’s HIPPA policy is posted and I understand my rights and the office’s procedures as stated in the policy. A personal copy is available upon my request. During today’s visit, and subsequent Recall visits, I understand that the Doctor will provide Orthodontic treatment recommendations. I understand that there are risks associated with any Orthodontic treatment plan. I understand that I am always welcome to review the treatment recommendations with the Doctor and to voice any concerns that I may have. I hereby consent to the making of diagnostic records, including x-rays and give consent to the Doctor and his staff to provide orthodontic treatment prescribed by the Doctor for the patient. I hereby authorize the Doctor to provide other health care providers with information regarding the patient as deemed appropriate. I understand that once released, the Doctor and his staff have no responsibility for any further release by the individual receiving this information.
Patient Signature:
Date: