Confidential Patient Information (New Patients)
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family who are or have been patients in our practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
What is the patient's main orthodontic concern?
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics? (If not please write "None" for required questions)
No
Yes
If so, please name the Insurance Company:
Member ID Number:
Group ID Number:
Responsible Party:
Employer:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Please respond to the following by selecting YES or No (if YES, please fill in details). Parents/guardians please respond for minors.
Injuries to face, jaw, mouth, or teeth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Thumb or tongue habit?
No
Yes
Frequent pain, tenderness, or noise in jaw?
No
Yes
Habits such as grinding or clenching?
No
Yes
Loud snoring during sleep?
No
Yes
Medical History
Please respond to the following by selecting YES or No (if YES, please fill in details). Parents/guardians please respond for minors.
Are you taking any medications/supplements?
No
Yes
Are you taking or have you ever taken bisphosphonates for osteoporosis or other bone diseases?
No
Yes
Are you allergic to any medication/latex/metals/materials/anesthetics?
No
Yes
Do you have a history of a major illness, operation, or accident?
No
Yes
Does your physician recommend premedicating with antibiotics prior to dental procedures?
No
Yes
If you have any of the following conditions, please explain in the box below:
Abnormal bleeding/ hemophilia, anemia, arthritis, asthma or hay fever, bone disorders, cancer, chemotherapy treatment, congenital heart defects, diabetes, dizziness, epilepsy, gastrointestinal disorders, growth disorders, heart problems or heart murmur, hepatitis or liver problems, herpes, high blood pressure or hypertension, HIV/AIDS, hormone therapy, kidney problems, nervous disorders, pneumonia, radiation treatment, rheumatic fever, sleep apnea, stroke, tuberculosis, tumor
Female patients only:
Are you pregnant?
No
Yes
If patient is under 16, has menstruation started?
No
Yes
If menstruation has begun, please indicate month/year it began:
*
I have read and understand the above questions. I will not hold my orthodontist or any member of the practice responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will inform the practice.
*
I have read and agree to the
BMO Appointment Policy
.
*
I have received access to the
BMO HIPAA Notice of Privacy Practices
. This notice is also available on request at the office.
I give consent to release of images as described in the
BMO Social Media and Photo Release Policy
.
Signature
Date