Confidential Patient Information

* Last Name:
* First Name:
Prefers to be called:
* Birthdate:
* Gender:
Social Security #:
* Marital Status:
* Address:
* City:
* State:
* Zip:
* Primary phone for appointment reminders:
Email address for appointment reminders:
Employer:
Occupation:
Do you prefer to receive appointment reminders by:

Closest Relative/Emergency Contact

* Spouse or closest relative's name(s):
Title:
* Relationship to Patient:
Address (if different than patient address):
Home phone:
Cell phone:
Work phone:

Financial Party Information

* First Name:
* Last Name:
Relationship to Patient:
* Address:
* City:
* State:
* Zip:
Email:
* Main Phone:
Secondary Phone:
Social Security Number:
Employer:
Occupation:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Birthdate:
Social Security Number:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:

Dental History

Dentist Name:
Dentist City:
Last DDS visit date:
Reason for visit:
Next appointment:
Other dentist/dental specialists now being seen: Name:
Address, City, State:
Reason:
What concerns you about your teeth?
What is the patient's main orthodontic concern?
It is very important to our doctors that their plan for the patient's smile matches your goals. Please rank the following to help guide their treatment recommendations during the consultation (1 - Most Important, 5 - Least Important):
* Improved Bite
* Esthetic Result
* Speed of Treatment
* Cost of Treatment
* Esthetic/non-visable treatment (clear braces or clear aligners)
Why did you select our office?
* Has the patient had any previous orthodontic consult or treatment?
If yes, please describe:
Have any other family members been treated in this office? Please name them:
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain:
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 primary or permanent teeth?
* Clench or grind teeth?
* Clicking or locking in jaw joints?
* Difficulty breathing through nose?
* Frequent canker sores or cold sores?
* Frequent oral habits (finger sucking, gum chewing, etc.)?
* Gum disease?
* Jaw fractures, cysts, or mouth infections?
* Lost or broken fillings?
* Missing or extra permanent teeth?
* Mouth breathing habit or snoring at night?
* Root canals or pupotomies?
* Permanent or extra teeth removed?
* Sensitive or sore teeth?
* Soreness in jaw or face muscles?
* Speech problems or therapy?
* Teeth that irritate tongue, cheek, lip, etc?
* Treated for "TMJ" or "TMD" problems?
* Trouble associated with previous dental treatment?
* Have you ever had an orthodontic consultation or treatment before now?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

* Has the patient (or their parents or siblings) ever had a severe allergic reaction, unusual dental problems, jaw size imbalance, or other severe medical conditions?
Please list any medications, nutritional supplements, herbal medications, or non-prescription medicines, including fluoride supplements, currently being taken by the patient and why they are being taken:
Have you ever taken any medications to strengthen your bones? Please describe:
* Does the patient need to take antibiotic premedication before any dental procedures?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women? Are you pregnant?
Are you trying to become pregnant?
* Does the patient currently have (or ever have had) a substance abuse problem, use tobacco, or vape?
* Does the patient need extra attention for orthodontic visits for reasons such as dental anxiety, ADHD, Autism, Aspergers, Down Syndrome, or sensory disorder?
Allergies or drug reaction to:
* Acrylics?
* Ibuprofen or Tylenol?
* Latex?
* Local anesthetics (novacaine, lidocaine, xylocaine)?
* Metal (jewelry, clothing snaps)?
* Penicillin or other antibiotics?
* Other?
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.
* Abnormal swallowing (tongue thrust)?
* Angina, arteriosclerosis, stroke or heart attack?
* Anemia, prolonged bleeding or excessive bruising?
* Arthritis or joint problems?
* Asthma, sinus problems, hayfever?
* Bleeding gums, bad taste or mouth odor?
* Birth defects or hereditary problems?
* Bone fractures or major injuries?
* Cancer, tumor, radiation treatment or chemotherapy?
* Chest pain, shortness of breath, tire easily, swollen ankles?
* Diabetes or low blood sugar?
* Do you eat a well-balanced diet?
* Food impaction between the teeth?
* Frequent ear infections, colds, throat infections?
* Frequent headaches or migraines?
* Gonorrhea, Syphilis, Herpes, other Sexually Transmitted Disease?
* Heart defects, heart murmur, rheumatic heart disease?
* Hepatitis, jaundice, or liver disease?
* High or low blood pressure?
* History of eating disorder (anorexia, bulemia)?
* History of Osteoporosis?
* HIV or AIDS?
* Immune system problems?
* Injury to face, head, or neck?
* Kidney problems?
* Mental health disturbance or depression?
* Polio, Mononucleosis, Tuberculosis, Pneumonia?
* Ringing in ears, difficulty in chewing or opening jaw?
* Seizures, fainting spells, neurological problem?
* Skin disorder (other than common acne)?
* Stomach ulcer, hyperacidity, acid reflux?
* Thyroid or endocrine problems?
* Tonsil or adenoid condition?
* Vision, hearing, or speech problems?
* Have you ever taken intravenous bisphosphonates such as Zomela (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
* Have you ever taken oral bisphosphonates such as Fosomax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for any disorder?
If any of the above medical questions were answered 'Yes' , please explain:

Complete if Patient is Under 18

What are your hobbies/activities?
Do you play a musical instrument?
What school do you attend?
Custodial parent(s) names:
Patient lives with:
Who has authority to make medical decisions:
Father's full name:
Occupation:
Email Address:
Address:
Phone Number:
Mother's full name:
Occupation:
Email Address:
Address:
Phone Number:

Your Protected Health Information Designees

Please list below those individuals (designees) with whom we can discuss your health information. These persons (designees) will also be able to call the office on your behalf. For example: if you are 18 or above, and your parents are financially responsible for your treatment please list them.
Designee Name:
Relationship to Patient:
Designee Name:
Relationship to Patient:
Designee Name:
Relationship to Patient:

Informed Consent for Initial Orthodontic Evaluation

In the vast majority of orthodontic cases, significant improvements can be achieved with informed and cooperative patients. Orthodontic treatment is an elective procedure and it, like any other treatment of the body, has certain inherent risks and limitations. These seldom prevent treatment, but should be considered before beginning treatment. Please feel free to ask any questions at any time.
* Relationship to Patient: