Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Emergency Contact Information
Name:
Address:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the Patient need to premedicate prior to dental visit?
No
Yes
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.
Chipped or injured permanent teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Other periodontal (gum) problems?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Penicillin or other antibiotics?
No
Yes
Please list any other drug allergies or sensitivities 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.
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Bone fractures or trauma to face or jaw?
No
Yes
Cancer?
No
Yes
Diabetes?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart murmur?
No
Yes
High blood pressure or hypertension?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' or any additional medical conditions, please explain:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.
I have read and agree to the HIPAA Notice of Privacy Practices (available on our website).