Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Preferred Pronoun(s):
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Dental Office/Dentist Name:
Physician Name:

Responsible Party Information

Responsible Party 1
First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Social Security Number:
Responsible Party 2
First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Social Security Number:

Dental Insurance Information

Primary Insurance
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
# of Years Employed:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Secondary Insurance
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
# of Years Employed:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:

Other Information

School Name:
Sports/Hobbies:
Musical Instruments Played:
Names of other children/siblings:
Age:
Names of other children/siblings:
Age:
Names of other children/siblings:
Age:

Medical Information

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Select here if all answers BELOW are NO
Heart Disease
Respiratory Disease
Blood Disease
Liver Disease
Yellow Jaundice
Stomach Disease
Thyroid Disease
Venereal Disease
Intestinal Disease
Bone Disease
Hearing Issues
Nervous/Emotional Issues
High/Low Blood Pressure
Endocrine Issues
Problem with Wounds Healing
Any Tumors/Cancer
Heart Murmur
Acquired Immune Deficiency
Arthritis
Mononucleosis
Hepatitis
Polio
Diabetes
Anemia
History of Fainting or Dizziness
Hemophilia
Does Patient have Drug Addiction
Rheumatic/Yellow/Scarlet Fever
Emphysema
Epilepsy
Asthma/Hay Fever
Tuberculosis
Any Broken Bones
Has Patient Had Fever Blisters
Radiation Therapy
Chemical Therapy
Blood Transfusions
Is Patient Pregnant
Is Patient on a Diet
Does Patient Smoke
Is Patient Under Medical Care
Is Patient in Good Health
Height/Weight Normal for Age
Has Patient Reached Puberty
Patient Taking Any Medications?
If yes, please list:
Any Allergies?
If yes, please list:
Any condition/disease/problem not listed?
If yes, what:

Dental History

Has Patient seen a General Dentist in the last year?
Any pain, clicking, or discomfort near ears/jaw?
Has mouth/face/teeth been injured by fall or accident?
Have you been informed of missing/extra permanent teeth?
Has patient’s tonsils/adenoids been removed?
Does patient snore?
Does patient have sleep apnea?
Is patient happy with their smile?
Does patient want to improve their smile/bite?
Does patient mind wearing braces/clear aligners?
Has a Physician/Dentist advised taking antibiotics before any dental work?
Does patient have or ever had any of the following habits:
Cheek, tongue, lip chewing
Mouth Breathing
Grinding Teeth
Speech Issues
Thumb sucking
Fingernail Biting
Tongue Thrusting
Has patient been examined by an orthodontist before?
If yes, when?
In your own words, what is your main concern orthodontically?
What would you like orthodontic treatment to accomplish?

Privacy Release (Please read Notice of Privacy Practices)

I acknowledge that I have received a copy of the Notice of Privacy Practices. I consent to disclosure of any information deemed necessary in connection with my treatment and with insurance payments. The information I have given today is correct to the best of my knowledge, and it will be held in the strictest confidence. I will update the office on any changes in medical status. I authorize and request my insurance company to pay directly to the orthodontist insurance benefits otherwise payable to by me. I understand I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.

Patient/Parent Signature:
Date: