Welcome to Mongiovi Orthodontics
We would like to welcome you and your child to our office. Our goal is to make every child’s visit pleasant and educational.
We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
Tell us about your child
Date:
Gender:
Male
Female
Other
Child's First Name:
Child's Middle Initial:
Child's Last Name:
Nickname:
Age:
Date of Birth:
School:
Grade:
Hobbies/Sports:
Child's Home #:
Child's Address:
City:
State:
Zip:
Who is accompanying your child today?
Name:
Relation:
Whom may we thank for referring you?
Siblings Names with Ages:
Parent/Guardian Information
Parent/Guardian 1 Information
Mother
Father
Guardian
Step-Parent
Name:
Date of Birth:
Marital Status:
Single
Married
Divorced
Widowed
Separated
If Married, name of Spouse:
If divorced or separated, who has custody of the child?
Address:
Employer:
Title:
Employer Address:
Work #:
Cell #:
Email Address:
How long at current job?
SSN:
Parent/Guardian 2 Information
Mother
Father
Guardian
Step-Parent
Name:
Date of Birth:
Marital Status:
Single
Married
Divorced
Widowed
Separated
If Married, name of Spouse:
If divorced or separated, who has custody of the child?
Address:
Employer:
Title:
Employer Address:
Work #:
Cell #:
Email Address:
How long at current job?
SSN:
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.
I am the patient, I am over the age of 18 and am the Responsible Party for myself. My information is listed below.
Patient is a minor or is unable to be their own Responsible Party. Their Responsible Party is listed below.
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.
In case of an emergency, whom do we contact?
Name:
Relation:
Phone #:
Insurance Information
Primary Insurance
Dental Coverage?
Yes
No
Orthodontic Coverage?
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Phone #:
Group #:
Policy Owner Name:
Date of Birth:
Social Security or Patient ID Number:
Secondary Insurance
Dental Coverage?
Yes
No
Orthodontic Coverage?
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Phone #:
Group #:
Policy Owner Name:
Date of Birth:
Social Security or Patient ID Number:
Medical History
Patient's General Health:
Good
Fair
Poor
Name of Physician:
Date of last visit:
Has puberty begun?
Yes
No
Is the patient currently under the care of a physician?
Yes
No
If yes, please explain:
Is your child taking any medications?
Y
N
If Yes, please list all medications:
Does your child have any drug or non-drug allergies?
Y
N
If Yes, please describe all allergies:
Is the patient allergic to any of the following?
Metals
Y
N
Plastics
Y
N
Latex
Y
N
Penicillin
Y
N
Antibiotics
Y
N
Dental Anesthetics
Y
N
Other
Y
N
If you answered "yes" to any of the above, please describe.
Please check Yes (‘Y’) or No (‘N’) whether your child has a history of the following:
Abnormal Bleeding
Y
N
ADD/ADHD
Y
N
Anemia
Y
N
Arthritis
Y
N
Artificial Bones/Joints
Y
N
Asthma/Diff. Breathing
Y
N
Autism
Y
N
Back Problems
Y
N
Blood Disease
Y
N
Blood Transfusion
Y
N
Cancer/Chemotherapy
Y
N
Congenital Heart Defect
Y
N
Diabetes
Y
N
Drug/Alcohol Abuse
Y
N
Emphysema
Y
N
Fainting Spells
Y
N
Fever Blisters/Herpes
Y
N
Glaucoma
Y
N
Handicaps/Disabilities
Y
N
Hearing Impairment
Y
N
Heart Attack
Y
N
Heart Murmur
Y
N
Heart Surgery/Pacemaker
Y
N
Hepatitis
Y
N
High/Low Blood Pressure
Y
N
HIV+/AIDS
Y
N
Kidney/Liver Problems
Y
N
Psychiatric Problem
Y
N
Rheumatic/Scarlet Fever
Y
N
Severe/Frequent Headaches
Y
N
Shingles
Y
N
Sickle Cell Disease/Trait
Y
N
Sinus Problems
Y
N
Thyroid Disease/Malfunc.
Y
N
Tonsils/Adenoids Removed
Y
N
Tuberculosis
Y
N
Venereal Disease
Y
N
Epilepsy/Seizures
Y
N
Mitral Valve Prolapse
Y
N
Ever been hospitalized?
Y
N
Please provide additional information if you checked YES to any of the above:
Dental History
General Dentist:
Dentist Phone #:
Last Visit Date:
Has the patient been evaluated or had orthodontic treatment before?
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
Have you been informed of any missing or extra permanent teeth?
Yes
No
Does the patient have any pain or tenderness in the jaw joint (TMJ/TMD)?
Yes
No
Does the patient have any speech problems?
Yes
No
Does the patient currently have a thumb or finger sucking habit?
Yes
No
How often does the patient brush his/her teeth daily?
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/Guardian Signature:
Date: